By Jason McCormick Vice President, Partner Services at Fusion5 The unknown is responsible for more last-minute decisions and changes in plans than any other factor when determining outcomes. Unknown variables can be the difference in an experiment’s success or failure. The same has held true as many service providers are struggling to find success in the Center for Medicare & Medicaid Innovation’s (CMMI) Bundled Payment for Care Improvement-Advanced (BPCI-A) initiative, which is aimed at lowering healthcare expenditures through improved coordination of care. Those that are finding early success in the program are identifying the unknown element as quickly as they are able to schedule surgery. The Bundled Payment for Care Improvement-Advanced initiative is designed around a model of care based on bundled services delivered during a specific period of treatment. Based on the model, providers are now finding themselves accountable for the overall cost of care provided to the beneficiary during the episode period. This idea of accountability is radically different than the mindset most surgeons have had in previous years, as their biggest concern was their Medicare Average Length of Stay. Providers are now being held responsible for all the services that the patient receives in the post-acute period which, in the case of BPCI-A, lasts for 90 days. So, physicians who are participating in BPCI-A in the total joint replacement of the lower extremity (hip, knee, ankle) episode, are now having to forecast and identify, if possible, which services patients will need once they are discharged from the hospital. Not only do they have to identify medical needs after surgery, they are now being charged with taking into account all of the patient’s socio-economic needs and how those factors may affect the overall cost, and outcome, of the episode period. Factors such as in-home support after surgery, access to transportation to attend outpatient follow-up or therapy appointments, and environmental constraints that may exist in the patient’s home have each attributed for inappropriate admissions to Inpatient Rehab or Skilled Nursing facilities. The costs associated with these inappropriate admissions have been reimbursed by Medicare under the fee-for-service model for decades. These are now the same services that Medicare is trying to reduce through the implementation of programs such as BPCI-A. In order to identify and plan for these “previously unknown” factors, providers need to begin having different conversations with patients, and begin having them sooner. The majority of services targeted in the BPCI-A program are elective surgeries that are scheduled weeks, if not months, prior to the date of service. Providers need to begin asking questions about socio-economic factors and addressing potential hurdles long before the patient being admitted to the hospital for surgery. Patients need to know that they should arrange for a family member to be present for the first few days after discharge from the hospital, and physicians should know if a patient is not going to have access to transportation to make it to their outpatient physical therapy appointments that are scheduled a few days post-op. Having these crucial conversations earlier in the process of determining if a patient is a surgical candidate removes many of the “unknown” issues that show up a day or two after surgery. Patients should ensure that their fear of the unknown is addressed also. Patients need to be reminded constantly of what is normal and expected after surgery, so that unexpected emergency room trips are removed from the post-op period. Addressing patients’ fears by simply reassuring them that you and/or your staff are available to answer questions as they arise can prevent anxiety about going home after surgery. After all, isn’t it the fear of the unknown that is the first thought that creeps into our heads when we don’t have someone available to be our sounding board? By preparing for the unknown, providers can ensure that the groundwork is laid for successful outcomes and the number of failures, and overall expenditures, is reduced. Having obtained successful results in reduction of overall cost and utilization of unnecessary post-acute services, Fusion5 Healthcare Solutions helps providers identify potential opportunities and implement processes to achieve success in quality improvement programs. If you would like to discuss your provider’s roadmap to being successful in any quality improvement program, or additional strategies related to BPCI-A or CJR, please contact

Leave a Reply

Your email address will not be published. Required fields are marked *