Archive Orthopedic Surgery 2018

Keeper of the Bundle

Tips for succeeding with orthopedic bundled payment models.

Robert Raspa

Robert Raspa, PA-C



In the old fee-for-service system, surgeons were paid to perform poorly. Even incentivized to do so. Think about it. If surgeons had to readmit a patient to the hospital because of, let's say, a site infection, severe pain or a failed surgery, they'd submit a bill to the payer and get reimbursed. No questions asked. A complication could lead to multiple reimbursable surgeries. But the days of How much can we be reimbursed? are long gone, replaced by value-based programs like bundled payments that ask How much can we save?

Better outcomes at lower costs. That's the mantra of the orthopedic bundled payment model. By their nature, bundles reward high-quality work at a much lower cost and encourage us to take exceptional care of our patients. But when patients hear "bundle," for some reason they think they're getting a no-frills, bargain-basement joint replacement. In actuality, of course, they're getting our very best care because we, the providers, not the payers, are assuming all the clinical and financial risk of surgery that payers traditionally managed.

The most common type of bundle is the prospective bundle, so named because you prospectively assume that, if all goes according to plan and there are no complications, x is the cost for the payer and y is the cost for each individual component of care. To succeed with a prospective bundle, you must eliminate waste and reduce unnecessary spending by closely managing the patient and standardizing care.

The math is 3rd-grade simple: Providers who cut healthcare costs and meet quality metrics might share in the savings, whereas providers who go over budget or do not meet quality metrics might see a financial loss on care episodes. But it's not just addition and subtraction between payer and provider. It's a continuum of care involving payer, provider and patient, as well as the hospital or surgery center, rehab, durable medical equipment (DME) suppliers and all others involved in the patient's care in ways small and not so small.

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