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  • Study of Health System Reveals Good Functional Outcomes for Patients in Bundled Care Model

    Bundled care models for total joint arthroplasty (TJA) may be popular with payers and policy makers, but do they work for patients? A new study says yes.

    Researchers arrived at their conclusion after tracking TJA episodes in the University of Utah health care system during its switch from a more traditional approach to Medicare's Bundled Payment Care Improvement (BCPI) model 2. Similar to other bundled care models, the BPCI reimburses providers a set amount for an entire episode of care, from admission to 90 days after the patient is discharged, rather than for specific services provided during care.

    The before-and-after pictures focus on functional recovery, based on data from 680 prebundle and 1,216 postbundle patients gathered between 2014 and 2016 (the health system launched the BCPI in July 2015). Researchers used the Activity Measure for Post Acute Care (AMPAC) mobility assessment and the PROMIS Physical Function Computer Adaptive Test (PF-CAT) to track function outcomes. The AMPAC was used at various points during the hospital stay, and the PF-CAT tracked function presurgery and then 2 weeks, 6 weeks, and 12 months afterwards. Results were published in Arthroplasty Today.

    APTA members Joshua Johnson, PT, DPT, ATC; Caitlin Miller, PT, DPT; Julie Fritz, PT, PhD, FAPTA; and Robin Marcus PT, PhD, were among the study’s authors. Johnson is a recipient of the 2015 Florence P. Kendall Doctoral Scholarship and a 2017 Promotion of Doctoral Studies I Scholarship from the Foundation for Physical Therapy Research, both of which were used to support the study in part. APTA also provided partial funding for the study.

    Limited to elective procedures only, the study included 1,666 patients associated with 1,896 TJA episodes. The majority of TJA procedures were for knee replacement (57.9%). Patients had an average age of 62, and most were women (57.3%). Here's what researchers found:

    • Postoperative mobility measured through the AMPAC was slightly better for the postbundle group, but not significantly so—and only at day 0. By days 1 and 2, there were no differences in average AMPAC scores.
    • The PF-CAT also uncovered no significant differences between the pre- and postbundle groups at 12 months or any earlier points.
    • The postbundle group averaged slightly shorter hospital stays than the prebundle group, with an average stay of 2.1 days compared with the prebundle group's average of 2.3 days.
    • Bundled care was associated with decreased odds of patients being discharged to a postacute care (PAC) facility: in the study, 10.9% of the postbundle patients were discharged to a PAC, compared with 26.9% of the prebundle group.

    "The big takeaway here is that, at least in the health system in this study, we see that joint replacement bundles achieve patient outcomes that are similar to nonbundled systems, and that's good news," said Heather Smith, PT, MPH, APTA director of quality. "The whole basis of the shift to bundled payment models is to control and decrease costs while still achieving good outcomes, and that's what seems to have happened here."

    Smith acknowledges that part of the study's positive results may be due to overall changes made to TJA care in the year prior to the system's switchover to a bundle model—changes that included adding a swing shift for inpatient physical therapy staff to ensure earlier ambulation postsurgery, as well as greater emphasis on patient education and increased crossdisciplinary work. But she sees this as more good news for bundled care models.

    "The changes the system made to its care pathways are part of the success of this study, but the important point is that the bundled model could absorb them," Smith said. "These kinds of redesigns applied to value-based models represent some real opportunities for physical therapy to become an even more important component of care."

    The results are encouraging for another reason: bundled care is probably here to stay. While voluntary Medicare models such as the BCPI have been around for years, a mandatory Medicare bundle program, known as the Comprehensive Care for Joint Replacement (CJR) was introduced in 2016 and affected some 800 hospitals in 67 geographic areas. The program has been scaled back since then and now applies to about 450 hospitals in 34 geographic areas, but the US Centers for Medicare and Medicaid Services (CMS) doesn't seem poised to dismantle the program—particularly if data show decreased costs and better patient outcomes.

    "CMS may have tapped the brakes on its move toward bundled care in 2017, but it's still moving and focused on shifting to value-based payment models," Smith said. "And if more studies emerge like this one showing that patient outcomes are unaffected by the change, that focus will likely increase."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.


    • Certainly there is value in to these programs for collaboration and outcomes. Things to consider: differences in outcomes and expense with physician practice versus hospitals as convener, comorbidities/acuity of patients has not been studied in depth (opinion/observation: healthier individuals are prioritized for surgery post-bundle while fewer unhealthy patients receive surgery, question long-term healthcare costs of not doing surgery on these individuals), length of stay in hospital may go up in effort to decrease the number of patients going to PAC facility putting more strain on hospital throughput and acute care therapists, lack of standardization of pre-op screening and patient optimization by PT and MD.

      Posted by Melissa White PT DPT on 5/8/2019 4:04 PM

    • Average age of 62???? These patients are not even medicare age and they are going to infer that bundled payments for complex medical patients that are over the age of 65 will benefit the patient's outcome and also the low on the reimbursement end Physical Therapist.... Sorry APTA I don't know where you are heading.

      Posted by James Trout on 5/8/2019 6:38 PM

    • shorter hospital stay and decreased incidence of PAC imply that decision makers opted for the least expensive options in order to maximize profit.

      Posted by Trisha Brabender on 5/9/2019 1:29 PM

    • My question is how many pain medications Rx or over the counter did the bundled patients require in comparison to other venues of treatment from beginning to end of the 12 months of reporting I am beginning to have this question regarding most studies that pretty much simplify therapy to exercises and a little bit of hands on treatment without the use of modalities and other interventions.

      Posted by Kathryn Hammer on 5/11/2019 11:18 AM

    • I hope the APTA will advocate for private practice when reviewing bundled payment. The comments in this article only mention POPS and hospital based PT. It will be very difficult for private practices to participate in the bundled model without significant organization and assistance from the APTA and state PT associations.

      Posted by Josh Laughlin on 5/13/2019 3:20 PM

    • I agree with the comment about this study average age being well below the older, chronically ill TJR patients we see at our facility. Pre-optimization is a work in progress with some facilities having formal clinics for medical/rehab pre-screening and others are piece-meal. We have identified patient outliers that would cancel surgery until addressed by a specialist of the PCP. We continue to struggle with patients who are expecting skilled nursing following surgery because they have poor support for discharging directly home making it a hybrid social/medical issue. It seems to me, these same researchers could analyze data from a subset of this study using patients 65 and older to see how bundling outcomes change.

      Posted by Karen Frederick on 5/14/2019 9:22 AM

    • I find the comments posted to be quite disheartening. The study demonstrates how a true interdisciplinary team can work to reduce the healthcare costs for our patients. If we want to continue to thrive as a profession we have to embrace change that demonstrates a positive effect on our health system. Reducing costs and maintaining outcomes is a win-win situation. Physical therapists have an ability to problem solve that will be immensely valuable in the changing healthcare landscape. Instead of complaining about the methods of this health system, we should be applauding their innovation. We have a duty to provide our patients with the highest quality care at the most affordable price.

      Posted by Anonymous on 5/14/2019 1:44 PM

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