With CMS bundled payments expanding from joint replacement procedures to hip and femur fracture surgeries, Johnson & Johnson Medical Devices Companies offer consulting and data insights to help health systems cope.

Christina Farup, MD, MS

The end of 2018 is approaching, which is the date CMS has set as the goal for when half of healthcare providers will be reimbursed under an alternative payment model. There will be many stepping stones on the path to value-based care, from the Comprehensive Care for Joint Replacement Model (CJR) to the recently proposed Episode Based Model (EBM). As the industry collectively works to address these and other proposed changes, many are feeling anxiety over the implications. For healthcare institutions looking to create real value, now is the time to enlist their partners and collaborate for guidance and execution.

The proposed "Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR)," which was announced on July 25, 2016, calls for a 90-day episodic payment model for surgical hip/femur fracture treatment (SHFFT) in existing CJR markets. For healthcare providers within the 67 included markets, this bundled payment model represents a significant departure from fee-for-service, in which payments are made for each individual component of care.

There are compelling reasons for hip fractures to be included in the CMS proposal. Approximately 258,000 people aged 65 and older were admitted for hip fractures in 2010, and the estimated lifetime cost for all hip fractures in a single year is $20 billion .¹ Additionally, these patients often present unique treatment challenges. While "geriatric" technically refers to those over the age of 65, the average age of a hip fracture patient is closer to 83 years of age, resulting in a greater number of patients who potentially arrive with unrelated complications, such as diabetes or heart failure.² Older hip fracture patients also face a higher risk of mortality in the first year post-fracture.³

Taking into account the many variables and challenges facing health systems along the entire path of care for these patients, it can be a daunting task to establish an action plan. But providers can turn to partners with proven experience to help.

The Johnson & Johnson Medical Devices Companies offer the DePuy Synthes Geriatric Fracture Program*, which can help health systems address the CMS proposed rule related to episodic payment programs for SHFFT. Through a team-based approach, the program begins the moment patients arrive in the emergency room and continues through discharge. Hospitals may benefit by improving patient care through early surgical intervention, management of co-morbidities, evidence-based care pathways, prevention of delirium, and early supported discharge. Data collection and quality metrics are included to track the performance of the program.

The results of the Geriatric Fracture Program have been quite positive. Coordinated programs for the management of geriatric patients with hip fractures have a proven track record in addressing morbidity, mortality, and costs.⁴  Studies have demonstrated statistically significant reductions in length of stay, post-operative delirium, and in-hospital post-operative falls.^{5, 6, 7}

For the program to truly work, hospitals begin with an opportunity assessment to determine a facility's readiness to implement this program. With clear understanding of their challenges, hospitals are

better equipped to leverage an action plan with opportunities for improvement delivered by multi-disciplinary teams. After assessment, our team works with hospitals to provide implementation support, targeted materials to aid hospital staff, and a performance dashboard. Health providers can expect a data-driven program that customizes protocols, pathways, and best practices, which have demonstrated the ability to deliver a reduction in length of stay and potentially delivering better outcomes.

Four components differentiate the Geriatric Fracture Program:

More than 150 hospitals and health systems in the United States have already begun improving the health outcomes and experiences for hip fracture patients using the DePuy Synthes Geriatric Fracture Program Geriatric Fracture Program.

As episodic payment bundles become more prevalent in healthcare, it will be critical for hospital executives to choose a partner with a proven track record of enabling improved care quality while also taking a programmatic approach that increases overall patient satisfaction, and decreases variability and cost along the way.

References

1. Smith et al. "Increase in Disability Prevalence Before Hip Fracture." Journal of the American Geriatrics Society. 2015 Oct;63(10):2029-35.

2. Swift CG. "Prevention and management of hip fracture in older patients." Practitioner. 2011 Sep;255(1743):29-33, 3. PubMed PMID: 22032113.

3. Haentjens P, Magaziner J, Colón-Emeric CS, et al. "Meta-analysis: excess mortality after hip fracture among older women and men." Ann Intern Med. 2010;152(6):380-390

4. Grigoryan KV, Javedan H, Rudolph JL. "Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis." Journal of Orthopaedic Trauma. Mar 2014;28(3):e49-55.

5. Literature Review, March 2015

·       Collinge CA, McWilliam-Ross K, Beltran MJ, Weaver T. "Measures of clinical outcome before, during, and after implementation of a comprehensive geriatric hip fracture program: is there a learning curve?" Journal of Orthopaedic Trauma. Dec 2013;27(12):672-676.

·       Dy CJ, Dossous PM, Ton QV, Hollenberg JP, Lorich DG, Lane JM. The medical orthopaedic trauma service: an innovative multidisciplinary team model that decreases in-hospital complications in patients with hip fractures." Journal of Orthopaedic Trauma. Jun 2012;26(6):379-383.

·       Khasraghi FA, Christmas C, Lee EJ, Mears SC, Wenz JF, Sr. "Effectiveness of a multidisciplinary team approach to hip fracture management." Journal of Surgical Orthopaedic Advances. Spring 2005;14(1):27-31.

·       Friedman SM, Mendelson DA, Bingham KW, Kates SL. "Impact of a comanaged Geriatric Fracture Center on short-term hip fracture outcomes." Archives of Internal Medicine. Oct 12 2009;169(18):1712-1717.

·       Miura LN, DiPiero AR, Homer LD. "Effects of a geriatrician-led hip fracture program: improvements in clinical and economic outcomes." Journal of the American Geriatrics Society. Jan 2009;57(1):159-167.

6. Literature Review, March 2015

·       Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. "Reducing delirium after hip fracture: a randomized trial." Journal of the American Geriatrics Society. May 2001;49(5):516-522.

·       Vidan M, Serra JA, Moreno C, Riquelme G, Ortiz J. "Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial." Journal of the American Geriatrics Society. Sep 2005;53(9):1476-1482.

·       Milisen K, Foreman MD, Abraham IL, et al. "A nurse-led interdisciplinary intervention program for delirium in elderly hip-fracture patients." Journal of the American Geriatrics Society. May 2001;49(5):523-532.

·       Deschodt M, Braes T, Flamaing J, et al. "Preventing delirium in older adults with recent hip fracture through multidisciplinary geriatric consultation." Journal of the American Geriatrics Society. Apr 2012;60(4):733-739.'

7. Stenvall M, Olofsson B, Lundstrom M, et al. "A multidisciplinary, multifactorial intervention program reduces postoperative falls and injuries after femoral neck fracture." Osteoporosis International: a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. Feb 2007;18(2):167-175.

^{* Provided through the DePuy Synthes Companies}

Christina Farup, MD, MS,  is vice president, Americas Health Economics and Market Access Lead, at Johnson & Johnson Medical Devices Companies. She holds a Master's of Science in preventive medicine from the University of Maryland and an MD from the Medical College of Virginia. She is also board certified in public health and preventive medicine.

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