Managing total knee replacement under value-based payments.

OBJECTIVES: To evaluate opportunity gaps and set outcome goals in knee replacement (KR) between a primary care group taking financial risk for managing its patients and 6 fee-for-service (FFS) orthopedic groups that serve their patients. STUDY DESIGN: The opportunity gap analysis was a cross-sectional evaluation of the outcomes of interest on a risk-adjusted basis using orthopedic groups, the primary care group's patients, and regional comparisons. The impact evaluation was a historical cohort comparison tracking outcomes of interest over the time frame of the intervention. METHODS: Using risk-adjusted Medicare data, we defined opportunity gaps in the following outcomes: density of KR surgery, site of KR surgery, postacute care placement, and complications. RESULTS: Opportunity gap analysis demonstrated the following variation on a regional basis: a 2-fold difference in density of KR, a 3-fold difference in outpatient surgery, and a 2.5-fold difference in institutional postacute care placement. In the impact evaluation comparing 2019 with 2021, the primary care group's patients had reduced density of KR surgeries from 15.5 per 1000 to 13.0 per 1000, an increase in outpatient surgery from 31.0% to 81.6%, and a reduction in institutional postacute care utilization from 16.0% to 6.1%. Less pronounced trends were seen in the region for all Medicare FFS patients. These results were achieved with stable complication rates, which had an observed/expected ratio of 0.61 in 2019 and 0.63 in 2021. CONCLUSIONS: We achieved alignment of incentives through use of performance information with specific goals and promise of referrals to value-based partners. This approach resulted in improved value to patients with no evidence of harm and is translatable to other specialty care and markets.

Improving Operating Room Efficiency: First Case On-Time Start Project.

BACKGROUND: Operating rooms (ORs) are costly to run, and multiple factors influence efficiency. The first case on-time start (FCOS) of an OR is viewed as a harbinger of efficiency for the daily schedule. Across 26 ORs of a large, academic medical center, only 49% of cases started on time in October 2011. METHODS: The Perioperative Services Department engaged an interdisciplinary Operating Room Committee to apply Six Sigma tools to this problem. The steps of this project included (1) problem mapping, (2) process improvements to preoperative readiness, (3) informatics support improvements, and (4) continuous measurement and feedback. RESULTS: By June 2013, there was a peak of 92% first case on-time starts across service lines, decreasing to 78% through 2014, still significantly above the preintervention level of 49% (p = .000). Delay minutes also significantly decreased through the study period (p = .000). Across 2013, the most common delay owners were the patient, the surgeon, the facility, and the anesthesia department. CONCLUSIONS: Continuous and sustained improvement of first case on-time starts is attributed to tracking the FCOS metric, establishing embedded process improvement resources and creating transparency of data. This article highlights success factors and barriers to program success and sustainability.