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Chen X, Geng S, Zhu Y, Li Q, Li Y, Yuan H, Jiang H. Impact of infection on healthcare costs and clinical outcomes in elderly hospitalized patients with multimorbidity. Heliyon 2024; 10:e31560. [PMID: 38826722 PMCID: PMC11141361 DOI: 10.1016/j.heliyon.2024.e31560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 09/10/2023] [Accepted: 05/17/2024] [Indexed: 06/04/2024] Open
Abstract
Background Elderly patients with multimorbidity are at higher risk of greater healthcare costs and poor outcomes due to decreased physical function. The aim of this study was to investigate the impact of infection on healthcare costs and poor outcomes in elderly hospitalized patients with multimorbidity. Methods We retrospectively enrolled 264 patients who met the inclusion criteria from the department of geriatrics of a large public hospital in Shanghai, China between January 2020 and December 2020. Patients were divided into two groups based on whether they had infection [infection present on admission (IPOA) or healthcare-associated infection(HAI)]. We recorded the basic information and follow-up information of all patients. The follow-up information included 30-day and 1-year all-cause readmission and mortality. Then we analyzed the association between infection and healthcare costs and clinical outcomes. Results Among 264 subjects, 47.73 % of them achieved IPOA or HAI. The 30-day poor outcomes rate was 45.45 %, and the 1-year poor outcomes rate was 78.41 %. Compared with subjects without infection, the number of drugs and the disease burden were greater in subjects with infection(P < 0.001). Subjects with infection had longer length of hospital stay(P < 0.001) and had greater healthcare cost(P < 0.001). Moreover, subjects with infection had higher poor outcomes rates of 30-day and 1-year(P < 0.001). Infection could predict greater total cost [odds ratio (OR): 1.32, 95 % CI: 1.18,1.49,P < 0.001], nursing cost(OR: 11.45, 95 % CI: 3.49,37.63,P < 0.001), and medicine cost (OR: 2.37, 95 % CI: 1.70,3.31,P < 0.001). In addition, infection was also independently associated with the 30-day poor outcomes rate(OR:3.07, 95%CI: 1.80,5.24,P < 0.001), but we found no association between infection and 1-year poor outcomes rate(OR:1.43, 95 % CI:0.73,2.79,P = 0.300) after adjustment. Conclusions Infection was a risk factor for higher healthcare cost and 30-day poor outcome rate in elderly hospitalized patients with multimorbidity.
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Affiliation(s)
- Xin Chen
- Department of Geriatrics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Department of General Practice, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Shasha Geng
- Department of Geriatrics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Department of General Practice, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yingqian Zhu
- Department of Geriatrics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Department of General Practice, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Qingqing Li
- Department of Geriatrics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Department of General Practice, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yang Li
- Department of Geriatrics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Department of General Practice, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Huixiao Yuan
- Department of Geriatrics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Department of General Practice, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Hua Jiang
- Department of Geriatrics, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
- Department of General Practice, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
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Bieganowski T, Christensen TH, Bosco JA, Lajam CM, Schwarzkopf R, Slover JD. Trends in Revenue, Cost, and Contribution Margin for Total Joint Arthroplasty 2011-2021. J Arthroplasty 2022; 37:2122-2127.e1. [PMID: 35533825 DOI: 10.1016/j.arth.2022.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/17/2022] [Accepted: 05/02/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Regulatory change has created a growing demand to decrease the hospital costs associated with primary total joint arthroplasty (TJA). Concurrently, the removal of lower extremity TJA from the in-patient only list has affected hospital reimbursement. The purpose of this study is to investigate trends in hospital revenue versus costs in primary TJA. METHODS We retrospectively reviewed all patients who underwent primary TJA from June 2011 to May 2021 at our institution. Patient demographics, revenue, total cost, direct cost, and contribution margin were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analysis was used to determine overall trend significance and develop projection models. RESULTS Total knee arthroplasty (TKA) insured by government-managed/Medicaid (GMM) plans showed a significant upward trend (P = .013) in total costs. Direct costs of TKA across all insurance providers (P = .001 and P < .001) and total hip arthroplasty (THA) for Medicare (P = .009) and GMM (P = .001) plans demonstrated significant upward trends. Despite this, 2011-2021 modeling found no significant change in contribution margin for TKA and THA covered under all insurance plans. However, models based on 2018-2021 financial data demonstrated a significant downward trend in contribution margin across Medicare (P < .001) and GMM (P < .001) insurers for both TKA and THA. CONCLUSION Physician-led innovation in cost-saving strategies has maintained contribution margin over the past decade. However, the increase in direct costs seen over the past few years could lead to negative contribution margins over time, if further efficiency and cost-saving measures are not developed. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Thomas Bieganowski
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | | | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Claudette M Lajam
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - James D Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Skeehan CD, Ortiz D, Sicat CS, Iorio R, Slover J, Bosco JA. The 2021 Centers for Medicare and Medicaid Services Fee Schedule's Impact on Adult Reconstruction Surgeon Productivity and Reimbursement. J Arthroplasty 2021; 36:3381-3387. [PMID: 34247872 DOI: 10.1016/j.arth.2021.06.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 05/07/2021] [Accepted: 06/05/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND On December 20, 2020, the Centers for Medicare and Medicaid Services (CMS) finalized its proposed rule: CMS-1734-P. This 2021 Final Rule significantly changed Medicare total joint arthroplasty (TJA) reimbursement. The precise impact on surgeon productivity and reimbursement is unknown. In the present study, we sought to model the potential impact of these changes for multiple unique practice configurations. METHODS A mathematical model was applied to CMS data to determine the impact of CMS-1734-F on multiple, theoretical TJA practice configurations. Variables tested were the annual percentage of revision vs primary arthroplasty cases performed and the annual percentage of operative vs office-based productivity. The model defined baseline annual surgeon productivity as the 2018 Medical Group Management Association hip and knee arthroplasty surgeon median productivity of 10,568 work relative value units (wRVUs). RESULTS All modeled simulations demonstrated a year-to-year increase in wRVUs independent of practice configuration. However, simulations that demonstrated less than a 3.35% increase in wRVUs from year-to-year saw a decrease in reimbursement. Those simulations with higher wRVU increases tended to have a higher percentage of revision vs primary arthroplasty cases and/or had annual productivity that was derived to a greater extent from office encounters than surgical cases. CONCLUSION The impact of CMS-1734-F will vary based on 3 factors: (1) the relative contribution of a surgeon's operative TJA practice compared with their office-based practice to their annual wRVUs; (2) the relative percentage of revision TJAs vs the percentage of primary TJAs performed; and (3) the relative percentage of primary TJA compared to non-arthroplasty surgeries as a component of overall operative practice. The decreased reimbursement will be disproportionately felt by arthroplasty surgeons who perform relatively fewer revision TJA procedures and whose office-based productivity makes up a smaller overall percentage of their annual workload.
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Affiliation(s)
| | - Dionisio Ortiz
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | | | - Richard Iorio
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - James Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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Li W, Liu W, Wang W, Wang J, Ma T, Chen J, Wu H, Liu C. Sinusoidal electromagnetic fields accelerate bone regeneration by boosting the multifunctionality of bone marrow mesenchymal stem cells. Stem Cell Res Ther 2021; 12:234. [PMID: 33849651 PMCID: PMC8042357 DOI: 10.1186/s13287-021-02302-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 03/22/2021] [Indexed: 12/26/2022] Open
Abstract
Background The repair of critical-sized bone defects is always a challenging problem. Electromagnetic fields (EMFs), used as a physiotherapy for bone defects, have been suspected to cause potential hazards to human health due to the long-term exposure. To optimize the application of EMF while avoiding its adverse effects, a combination of EMF and tissue engineering techniques is critical. Furthermore, a deeper understanding of the mechanism of action of EMF will lead to better applications in the future. Methods In this research, bone marrow mesenchymal stem cells (BMSCs) seeded on 3D-printed scaffolds were treated with sinusoidal EMFs in vitro. Then, 5.5 mm critical-sized calvarial defects were created in rats, and the cell scaffolds were implanted into the defects. In addition, the molecular and cellular mechanisms by which EMFs regulate BMSCs were explored with various approaches to gain deeper insight into the effects of EMFs. Results The cell scaffolds treated with EMF successfully accelerated the repair of critical-sized calvarial defects. Further studies revealed that EMF could not directly induce the differentiation of BMSCs but improved the sensitivity of BMSCs to BMP signals by upregulating the quantity of specific BMP (bone morphogenetic protein) receptors. Once these receptors receive BMP signals from the surrounding milieu, a cascade of reactions is initiated to promote osteogenic differentiation via the BMP/Smad signalling pathway. Moreover, the cytokines secreted by BMSCs treated with EMF can better facilitate angiogenesis and osteoimmunomodulation which play fundamental roles in bone regeneration. Conclusion In summary, EMF can promote the osteogenic potential of BMSCs and enhance the paracrine function of BMSCs to facilitate bone regeneration. These findings highlight the profound impact of EMF on tissue engineering and provide a new strategy for the clinical treatment of bone defects.
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Affiliation(s)
- Weigang Li
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Wenbin Liu
- Department of Orthopedics, Xiangya Hospital of Central South University, Changsha, 410008, Hunan, China
| | - Wei Wang
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jiachen Wang
- Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Tian Ma
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Jingyuan Chen
- Department of Cardiothoracic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China
| | - Hua Wu
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
| | - Chaoxu Liu
- Department of Orthopedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430030, Hubei, China.
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Navigating Ethical Practices in the Era of High Cost Hematology. Curr Hematol Malig Rep 2020; 15:401-407. [PMID: 33025550 DOI: 10.1007/s11899-020-00599-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE OF REVIEW In this review article, we will highlight ethical issues faced by hematologists due to a growing constellation of expensive diagnostics and therapeutics in hematology. We outline the important issues surrounding this topic including stakeholders, cost considerations, and various ethical challenges surrounding access to care, communication about costs, and individual vs. societal responsibilities. We review available tools to navigate these ethical themes and offer potential solutions. RECENT FINDINGS We identified several gaps in the literature on the topic of ethical issues in hematology treatment and supplement by non-hematological cancer and general medical literature. We propose proactive solutions to address these problems to include cost transparency, utilization of evidence-based decision making tools, application of the four quadrant approach to ethical care, and advanced systems-based practice curriculum for physician trainees.
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Pean CA, Lajam C, Zuckerman J, Bosco J. Policy and Ethical Considerations for Widespread Utilization of Generic Orthopedic Implants. Arthroplast Today 2019; 5:256-259. [PMID: 31286053 PMCID: PMC6588801 DOI: 10.1016/j.artd.2019.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Christian A Pean
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery, New York University School of Medicine, New York, NY, USA
| | - Claudette Lajam
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery, New York University School of Medicine, New York, NY, USA
| | - Joseph Zuckerman
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery, New York University School of Medicine, New York, NY, USA
| | - Joseph Bosco
- NYU Langone Orthopedic Hospital, Department of Orthopedic Surgery, New York University School of Medicine, New York, NY, USA
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Salem J, Paffenholz P, Bolenz C, von Brandenstein M, Cebulla A, Haferkamp A, Kuru T, Lee CT, Pfister D, Tsaur I, Borgmann H, Heidenreich A. Websites on Bladder Cancer: an Appropriate Source of Patient Information? JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2019; 34:381-387. [PMID: 29313299 DOI: 10.1007/s13187-017-1316-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
A growing number of patients search for health information online. An early investigation of websites about bladder cancer (BCa) revealed mostly incomplete and particularly inaccurate information. We analyzed the quality, readability, and popularity of the most frequented websites on BCa. An Internet search on www.google.com was performed for the term "bladder cancer." After selecting the most frequented websites for patient information, HONcode quality certification, Alexa popularity rank, and readability scores (according to US grade levels) were investigated. A 36-point checklist was used to assess the content according to the EAU guidelines on BCa, which was categorized into seven topics. The popularity of the 49 websites analyzed was average, with a median Alexa popularity rank of 41,698 (interquartile range [IQR] 7-4,671,246). The readability was rated difficult with 11 years of school education needed to understand the information. Thirteen (27%) websites were HONcode certified. Out of 343 topics (seven EAU guideline topics each on 49 websites), 79% were mentioned on the websites. Of these, 10% contained incorrect information, mostly outdated or biased, and 34% contained incomplete information. Publically provided websites mentioned more topics per website (median [IQR] 7 [5.5-7] vs. 5.5 [3.3-7]; p = 0.022) and showed less incorrect information (median [IQR] 0 [0-1] vs. 1 [0-1]; p = 0.039) than physician-provided websites. Our study revealed mostly correct but partially incomplete information on BCa websites for patients. Physicians and public organizations should strive to keep their website information up-to-date and unbiased to optimize patients' health literacy.
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Affiliation(s)
- Johannes Salem
- Department of Urology, University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany.
| | - Pia Paffenholz
- Department of Urology, University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | | | | | | | - Axel Haferkamp
- Department of Urology, University Medicine, Mainz, Germany
| | - Timur Kuru
- Department of Urology, University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Cheryl T Lee
- Department of Urology, University of Michigan, Ann Arbor, MI, USA
| | - David Pfister
- Department of Urology, University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
| | - Igor Tsaur
- Department of Urology, University Medicine, Mainz, Germany
| | | | - Axel Heidenreich
- Department of Urology, University Hospital Cologne, Kerpener Straße 62, 50937, Cologne, Germany
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8
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Stein SC. Cost-Effectiveness Research in Neurosurgery: We Can and We Must. Neurosurgery 2018; 83:871-878. [DOI: 10.1093/neuros/nyx583] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/15/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Sherman C Stein
- Perelman School of Medicine, Univers-ity of Pennsylvania, Philadelphia, Penn-sylvania
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Polacco MA, Pintea AM, Gosselin BJ, Paydarfar JA. Parotidectomy using the Harmonic scalpel: ten years of experience at a rural academic health center. Head Face Med 2017; 13:8. [PMID: 28490378 PMCID: PMC5426003 DOI: 10.1186/s13005-017-0141-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2017] [Accepted: 05/05/2017] [Indexed: 11/10/2022] Open
Abstract
Background Parotidectomy is one of the most commonly performed procedures by otorhinolaryngologists. Traditionally dissection is performed with a combination of a steel scalpel and bipolar cautery; however, starting in the early 2000s, the Harmonic scalpel has provided an alternative method for dissection and hemostasis. The purpose of this study is to compare operative time, blood loss, complications, and cost between the Harmonic scalpel and steel scalpel plus bipolar cautery for superficial and total parotidectomy. Methods Retrospective cohort of patients who underwent superficial or total parotidectomy with the Harmonic or cold steel between 2000 and 2015. Across 255 patients, comparison between operative time, blood loss, complications, and cost was performed. Results Superficial parotidectomy was performed on 120 patients with the Harmonic and 54 with steel scalpel. Total parotidectomy was performed on 59 patients using the Harmonic and 22 patients with cold steel. For superficial parotidectomy, the Harmonic reduced operative time (216 ± 42 vs. 234 ± 54 min, p = 0.03) and decreased blood loss (28 ± 19 vs. 76 ± 52 mls, p < 0.05). With total parotidectomy the Harmonic decreased operative time (240 ± 42 vs. 288 ± 78 min, p = 0.01) and reduced blood loss (38 ± 21 mls vs. 85 ± 55 mls, p < 0.05). There were no differences in complication rates between groups. Harmonic use was associated with surgical cost reduction secondary to reduced operative times. Conclusions The Harmonic scalpel decreases blood loss and operating time for superficial and total parotidectomy. Shorter operative times may decrease the overall cost of parotidectomy.
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Affiliation(s)
- Marc A Polacco
- Department of Otolaryngology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA. .,Dartmouth-Hitchcock Medical Center, One Medical Center Drive, Lebanon, NH, 03766, USA.
| | - Andrew M Pintea
- Department of Otolaryngology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Benoit J Gosselin
- Department of Otolaryngology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Joseph A Paydarfar
- Department of Otolaryngology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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Iorio R, Bosco J, Slover J, Sayeed Y, Zuckerman JD. Single Institution Early Experience with the Bundled Payments for Care Improvement Initiative. J Bone Joint Surg Am 2017; 99:e2. [PMID: 28060238 DOI: 10.2106/jbjs.16.00066] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The Centers for Medicare & Medicaid Services (CMS) implemented the Bundled Payments for Care Improvement (BPCI) initiative in 2011. Through BPCI, organizations enlisted into payment agreements that include both performance and financial accountability for episodes of care. To succeed, BPCI requires quality maintenance and care delivery at lower costs. This necessitates physicians and hospitals to merge interests. Orthopaedic surgeons must assume leadership roles in cost containment, surgical safety, and quality assurance to deliver cost-effective care. Because most orthopaedic surgeons practice independently and are not employed by hospitals, models of physician-hospital alignment (e.g., physician-hospital organizations) or contracted gainsharing arrangements between practices and hospitals may be necessary for successful bundled pricing. Under BPCI, hospitals, surgeons, or third parties share rewards but assume risks for the bundle.For patients, cost savings must be associated with maintenance or improvement in quality metrics. However, the definition of quality can vary, as can the rewards for processes and outcomes. Risk stratification for potential complications should be considered in bundled pricing agreements to prevent the exclusion of patients with substantial comorbidities and higher care costs (e.g., hip fractures treated with prostheses). Bundled pricing depends on economies of scale for success; smaller institutions must be cautious, as 1 costly patient could substantially impact the finances of its entire program. CMS recommends a minimum of 100 to 200 cases yearly. We also suggest that participants utilize technologies to maximize efficiency and provide the best possible environment for implementation of bundled payments. Substantial investment in infrastructure is required to develop programs to improve coordination of care, manage quality data, and distribute payments. Smaller institutions may have difficulty devoting resources to these infrastructural changes, although changes may be implemented more thoroughly once initiated. Herein, we discuss our early total joint arthroplasty BPCI experience at our tertiary-care academic medical center.
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Affiliation(s)
- Richard Iorio
- 1Department of Orthopaedic Surgery, New York University Langone Medical Center, New York, NY
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