Redefining Care Delivery One Episode at a Time

By Mark I. Froimson, MD, MBA; Michelle Schill, RN, BSN; Monica Deadwiler; Prashant Nayak; and Seth Vilensky, MBA

Innovation is the key to making our healthcare delivery system more effective and efficient. We traditionally think of innovation as a new device or drug, but patients tell us that the biggest need is coordinated care that is more user-friendly, accessible and affordable. Patients see us as working in a piecemeal fashion, each doing our jobs well but sometimes dropping the ball during care transitions. They want us to put care together — to bundle it for an episode and deliver it as one product.

Joint replacement is one of the most effective procedures in medicine, reliably relieving pain and restoring function. With demand for joint replacement expected to continue to rise significantly in the coming decades, the concern is that the associated costs will outpace the ability of our stretched system to afford this demand.

Two common criticisms of our delivery system today is that it is costly yet still fails to deliver a product that patients see as meeting their needs.

A potential solution

As Cleveland Clinic has examined ways to curtail costs, we have uncovered data that may help address both the need for more care coordination and the need to deliver care at a lower cost. After investigating the relative cost of a joint replacement among numerous surgeons within the system, we found significant variation in cost among providers without any difference in quality. In fact, lower cost surgeons had lower complication rates and lower readmission rates for the same procedure. When we delved deeper, we found that lower cost surgeons were achieving this cost advantage not through the use of less-expensive implants or technology but rather through better care coordination. It appeared that better coordination was not an expensive add-on that would increase cost; to the contrary, it appeared to decrease cost, representing an opportunity.

Redefining the episode of care

One of the keys to both care coordination and cost containment involves a paradigm shift that is at the heart of our innovative approach: viewing a procedure as an entire episode of care rather than just as the surgery itself. This way of thinking makes clear that what goes on before and after the surgery can have a significant impact on outcomes, patient satisfaction and cost. In fact, the greatest variation we found in the care delivered was in the discharge disposition of our patients and in the costs incurred after they left the hospital. From surgeon to surgeon, and from hospital to hospital, a patient’s likelihood of going home after surgery could vary by a factor of 10. The figure illustrates the dramatic variation in patients’ home-going rates by surgeon quintile. That degree of variation, coupled with the significant cost difference between discharging patients home vs. to a post-acute care facility, offers the potential for significant cost savings through better patient engagement and care coordination.

Figure. Variation in patients’ home-going rates by surgeon quintile. Each quintile represents 20 percent of surgeons with more than 20 cases in the period studied.
Population represents DRG 470, traditional Medicare patients, all hip and knee replacements.

A good match for new CMS initiative

The Patient Protection and Affordable Care Act of 2010 mandated the Centers for Medicare & Medicaid Services (CMS) to initiate a call for innovations in care delivery. One of these, the Bundled Payments for Care Improvement (BPCI) initiative, called for a program that incentivizes providers to come together and redesign care in a more coordinated and streamlined way. This program provided an opportunity to highlight our redesign efforts aimed at effectively delivering an episode of care that features optimum care coordination, patient-centeredness and shared decision-making while promoting high-quality, efficiently delivered healthcare.

To that end, Euclid Hospital, one of the community hospitals in the Cleveland Clinic health system, is collaborating with CMS to deliver innovative care under the BPCI initiative for MS-DRGs 469/470, primary total hip and knee arthroplasty. We believe that several factors have fully aligned Euclid Hospital with the BPCI initiative and prepared it to achieve the BPCI objectives: (1) our physician-led, group-model culture and strategy; (2) our operational capabilities and infrastructure; and (3) our clinical redesign initiatives and track record. A few of these factors merit additional discussion.

Leveraging access to information

Tracking outcomes and costs requires a robust infrastructure. Fortunately, Cleveland Clinic has invested in market-leading electronic health records, clinical information systems, and data warehouse and metrics capabilities (outcomes tracking, reporting and monitoring) that will enable successful tracking of our redesign efforts. A notable differentiated capability is the Orthopaedic & Rheumatologic Institute’s OrthoMiDaS data warehouse and patient registry database, which allows collection of patient-reported functional outcomes for our surgical patients. Collecting these patient-reported measures enables us to understand and research the impact of our interventions on patient function and quality of life.

Clinical redesign initiatives

Our Rapid Recovery Program (RRP) for Orthopaedics has emerged from Cleveland Clinic’s ongoing commitment to clinical redesign and identification of best practices that lead to improved outcomes. The RRP for Orthopaedics is designed to help total joint replacement patients progress to full mobility and home-based postoperative care as efficiently as possible. The RRP directly involves the patient in making decisions about his or her own preoperative, acute and postoperative care. It promotes collaboration, coordination and cooperation among the orthopaedic surgery practice, the acute care facility and post-acute medical providers (including inpatient physical and occupational therapists), case management, home care and outpatient therapeutics.

Expectations as the initiative proceeds

Based on 2009 Medicare fee-for-service volumes and reimbursements as provided in claims data received relative to this project, we estimate a significant savings potential over the three-year pilot period. We expect our care delivery redesign to result in:

• Better-prepared, actively engaged patients and families, with resulting increases in satisfaction

• Elevated quality of care through best practice modification

• Lower total cost of care as resource use is aligned more appropriately to patient- and episode-specific needs

We are excited to have an opportunity to pilot such an innovative initiative and are committed to its success, as it aligns with our fundamental values of seeking new methods to improve care delivery for the patients entrusted to us.

About the authors

Dr. Froimson (froimsm@ccf.org) is President of Cleveland Clinic’s Euclid Hospital and a surgeon in the Department of Orthopaedic Surgery, specializing in hip and knee replacement.