MaCalus V. Hogan, MD, MBA
Vice Chair, Orthopaedic Surgery
Senior Medical Director, UPMC Health Plan Orthopaedic and Musculoskeletal Care Services
Amy Helwig, MD, MS
Vice President, Quality Performance, UPMC Health Plan
Hip and knee joint replacement surgeries are some of the most frequently performed in the U.S. The Centers for Medicare and Medicaid Services (CMS) reports that upward of 400,000 procedures were performed in 2014, resulting in excess of $7 billion in care costs. CMS estimates the average Medicare expenditure for surgery, hospitalization, and recovery ranges from $16,500 to $33,000 across geographic areas.
Post-surgery infections or implant failures also contribute to costs. CMS estimates that complication and readmission rates can be three or more times higher at some facilities versus others.
The number of procedures stands to rise dramatically over the next decade, with estimates varying between nearly 200 to 700 percent. Data also points to a significant uptick in revision surgery as the population ages. Although these procedures are common, there is significant variation in medical costs, provider quality, and the patient experience. For these reasons, UPMC sought solutions to give patients greater access to facilities that provided higher quality outcomes and a better patient experience.
UPMC’s approach is a value-based system that follows tight pathways for delivering high-quality, cost efficient care. Our structure as an integrated delivery and finance system (IDFS)—a payer-provider—started over 20 years ago. It provides the necessary discipline to foster doctor-patient trust, align incentives, and drive value in the post-fee-for-service world.
Ahead of the curve
UPMC’s early work to establish value-based programs focused on primary care and joint replacement across western Pennsylvania and provided a foundation on which to build additional models.
These early pilot programs drove physician engagement, incentive alignment, network management, and collaboration across the enterprise. Critical to the success? Data. Our IDFS structure allowed us to provide data on the three main drivers of cost and outcome—financial, clinical, and quality—more efficiently than most traditional payers. This information facilitated the conversation around best practices, quality improvement, and value-added practices across our payer and provider arms.
The 2016 launch of the CMS Comprehensive Care for Joint Replacement (CJR) model created an opportunity for UPMC to further expand payer-provider collaborations. In addition to the CMS program, UPMC orthopaedic surgeons partnered with UPMC Health Plan to administer a bundle payment and quality incentive program for joint replacement paralleled with CJR requirements, resulting in the majority of patients being covered by a value-based program. This model accelerated clinical transformation, rapidly decreasing quality variations, including complications and readmissions. It underscored the importance of placing financial accountability and incentives for the episodic cost and quality across the spectrum of care. All of our CJR-mandated hospitals have been successful in the program.
Blazing the path
Our work to drive high-quality outcomes and address costs did not stop there. UPMC Health Plan recently established a Center of Excellence (COE) program for elective hip and knee joint replacement surgery to improve quality and reduce variation. Nine hospitals are currently participating with several more in the works. The program is open to any hospital in the UPMC Health Plan network that meets a robust, but achievable, set of requirements.
The UPMC Health Plan Hip and Knee Joint Replacement Surgery Center of Excellence program, developed in collaboration with the University of Pittsburgh Department of Orthopaedic Surgery and affiliated community surgeons, recognizes surgical facilities and orthopedic surgeons that demonstrate high quality outcomes, low complication rates, and the best patient experience for UPMC Health Plan members in need of joint replacement surgery. Programs must demonstrate the finest experience throughout the entire care process, from shared-decision making, to helping patients understand all their options (including non-surgical alternatives), toward recovery and return to full functional lifestyle. The pilot program resulted in surgical patients demonstrating significant functional improvement, with significant reductions in complications, readmissions, and post-acute care utilization and costs.
The journey to value-based care is ongoing, and we’re proud to not only be a part of this process, but to also lead the way as an IDFS. This structure is critical to empowering payers and providers to come together for the greater good—ensuring patients have access to both the highest quality and cost-efficient care.
We will continue pioneering in this arena by expanding our Centers of Excellence program, as well as our other value-driven initiatives that aim to provide the right care, to the right patient, at the right time.
To learn more about UPMC Health Plan, please visit www.upmchealthplan.com/.
This content was originally printed in Modern Healthcare’s September 23, 2019 Special Supplement “The 116th Congress on The State of Healthcare”