Guest Columns

What providers need to know about joint bundles

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Sharon Johnson
Sharon Johnson

At one time, I worked with a transitional care unit which was a preferred provider with a leading orthopedic practice in bundled payments for joint replacements. While very proud of the great work they did, they learned some hard lessons about rehab for orthopedic bundles. As many more new orthopedic bundles will soon be coming on the market under CMS value-based payments this April, post-acute care providers need to be talking with the hospitals – or bundle initiators or leads – in the planning stage, and not wait to be the downstream vendors with lots of imposed expectations but no part in the planning (or participation in the risk).

First, a clinically advanced orthopedic practice reduces variation as much as possible among its medical staff and standardizes each small step of joint replacement, from pre-surgery education, to implant, anesthesia, time in surgery, time in recovery, etc. However, generally, hospitals and orthopedists don't understand the incentives in post-acute care.

An advanced TCU rehab department is modeled more like a hospital inpatient department – they can provide therapy seven days a week, and staff the rehab department with their employed (not contracted) therapists. The therapy team can then follow the patient after SNF discharge in either outpatient rehab or home health care; while not the same therapist follows the patient, there is a warm hand-off, an introduction between therapist and patient before discharge to outpatient care.  

Consistency of therapy team, confidence in therapy, close communication around care plan, and feedback to the orthopedic team are all important components of success.

HOWEVER, the stakeholders in the bundle outside post-acute care do not understand a TCU's financial quandaries. A TCU's  biggest expense is in the first couple days – assessments, requirements of MDS (a charting system CMS requires of skilled nursing facilities, which is very detailed), and a Medicare payment determined by therapy minutes. The established benchmark for rehabbing patients participating in the bundles for this practice were between 5 and 7 days for knees, and between 7 and 10 days for hips.  Patients who need more time for a variety of reasons have a care plan and longer length-of-stay which reflects their greater complexities, and other factors; however, the outliers should be few enough so as not to impact the average.

The payment rate did not vary because the TCU was a preferred provider post-acute care.  In fact, because payment to SNFs is a daily rate, SNFs lose money and incur expense for faster turnaround in achieving patient goals on their bundle care plans and discharging in, for example, seven days as compared to fourteen days.  Likewise, SNFs incur more expense by staffing therapists seven days/week.  

However, in the healthcare reform space, it is the right thing to do – why should patients sit on Saturdays and Sundays, particularly if discharged from surgery and hospitalization later in the week?

The key statement to me in the CMS guidance for bundled joint replacements is that “Participant hospitals may assign various percentages of two-sided risk to collaborators.” Right now, post-acute care is a critical part of reducing costs and meeting quality standards, and instead of participating in the value proposition (better revenue/profit sharing) post acute provider only participate in greater expense.

Post acute care providers need to be at the table as bundles are designed, so that all parties in the continuum understand each others' worlds, incentives, limitations.

Sharon A. Johnson, MA, LNHA, is a consultant with Privot: Health Care Transitions. She can be reached at

Guest Columns

Guest columns are written by long-term care industry experts, ranging from academics and thought leaders to administrators and CEOs.