Abstract
Background
In surgeon controlled bundled payment and service models, the goal is to reduce cost but preserve quality. The surgeon not only takes on risk for the surgery, but all costs during 90 days after the procedure. If savings are achieved over a previous target price, the surgeon can receive a monetary bonus. The surgeon is placed in a position to optimize the patients preoperatively to minimize expensive postoperative readmissions in a high risk population. Traditionally, surgeons request that primary care providers medically clear the patient for surgery with cardiology consultation at their discretion, and without dictating specific testing. Our participation in the Bundled Payments for Care Improvement (BPCI) program for total hip and knee replacement surgeries since 1/1/15 has demonstrated a significant number of patients having costly readmissions for cardiac events.
Objective
To determine the medical effectiveness and cost savings of instituting a new innovative cardiac screening program (Preventive Cardio-Orthopaedics) for total hip and knee replacement patients in the BPCI program and to compare result to those managed in the more traditional fashion.
Methods
The new screening program was instituted on 11/1/17 directed by an advanced cardiac imaging cardiologist (EH). Testing included an electrocardiogram, echocardiogram, carotid and abdominal ultrasound, and coronary computed tomography angiography (CCTA). If needed, a 3 day cardiac rhythm monitor was also performed. Four of the ten physicians in our group performing hip and knee replacement surgeries participated. Charts of readmitted patients were reviewed to determine past medical history, method of cardiac clearance, length and cost of readmission.
Results
2,459 patients had total hip or knee replacement in the BPCI program between 1/1/15 and 10/31/17 prior to instituting the new program. All had complete 90 day postoperative readmission data supplied by the CMS, with 25 (1%) of these patients having readmissions for cardiac events for a total cost of readmissions of %149,686. 14 of 25 had a preoperative clearance by a cardiologist. In 19 of the 25 patients, the only preoperative cardiac screening tool performed was an electrocardiogram.
Since instituting the new program, 842 additional surgeries were performed, 463 by the four surgeons involved. 126 patients were agreeable to be evaluated through the Preventive Cardio-Orthopaedics program. 4 patients of the four physicians still screened via the traditional cardiac program had a cardiac event readmission. The average readmission hospital stay was 3.33 days at a total cost of %42,321. 2 patients of the four physicians evaluated by the Preventive Cardio-Orthopaedics program had a cardiac related readmission, at an average hospital stay of 2 days, and at a total cost of %10,091.
Conclusions
Risk sharing programs have forced surgeons to take a more active role in optimizing their patients medically; otherwise they will be penalized with a decreased reimbursement. Traditionally, we have abdicated this responsibility to primary care and cardiology physicians but have noted a high cardiac readmission risk. In response, we have begun using a unique cardiac screening model. Our preliminary experience predicts fewer cardiac readmissions thereby improving care, and at a lower cost.
