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News & Press: Industry News

Patient Optimization: The New Standard of Care

Thursday, December 14, 2017   (0 Comments)
Posted by: Ann Conrath, Signature Medical Group
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Many who work in orthopaedics are familiar with the Bundled Payment for Care Improvement (BPCI) initiative. BPCI is a voluntary initiative implemented by the Centers for Medicare and Medicaid Services (CMS) that aims to improve quality of care while decreasing costs for Medicare patients. The most popular clinical episode implemented in BPCI is total joint surgery for the lower extremity, which includes hip and knee replacements. Although many of the participants in BPCI are larger hospital systems, orthopaedic physician groups are also performing extremely well in the program.

Under BPCI Model 2, orthopaedic physician groups participating in BPCI are responsible for all patient costs during the 72 hours before surgery, the acute care stay, and through up to 90 days after the day of discharge. Since physicians are liable for a certain amount of financial risk in BPCI, physicians and clinical staff are incentivized to reduce unnecessary costs and services and individualize patient care with the goal of increased quality outcomes. Physician groups engaged in BPCI are generating new ideas and new ways of thinking for total joint surgery and patient care.

Although a significant amount of cost savings occurs as a result of streamlining and coordinating post-acute care, the majority of the effort to achieve cost-savings is performed in the preoperative phase of care. At least four weeks before surgery takes place, physicians and their clinical teams are conducting comprehensive risk assessments and optimizing patient health in order to determine the plan of care.

For many physician groups, patient optimization includes the use of clinical thresholds to determine when a patient is an appropriate candidate for elective surgery. Clinical thresholds are evidence-based guidelines that assess patient risk factors and comorbidities and identify risk factors to address with patients prior to surgery. Depending on the risk factors, surgery may be delayed until the patient’s risk factors are adequately managed. Through patient optimization, patients are more likely to have better surgical outcomes.

Examples of risk factors that need to be managed and criteria that need to be met prior to surgery include:

  • BMI
  •  A1C levels
  • Smoking cessation two weeks before surgery
  • Albumin levels
  • Mental health
  • Pre-habilitation appointment
  • Mandatory total joint class
  • Robust cardiac clearance

By implementing clinical thresholds and assessing patients’ risks prior to surgery, physicians are able to optimize aspects of patient health that may have otherwise gone unmanaged, potentially avoiding adverse outcomes after surgery. Since physicians have implemented clinical thresholds, patient outcomes have continued to improve. Below are patient outcomes data for 2016 compared to a baseline period (2009-2012) for 1,219 physicians:



Percentage Reduction (from baseline)*

90-day Readmission Rate


30-day Readmission Rate


Pulmonary Embolism during Index Admission


Surgical Site Infection


DVT During Index Admission


UTI During Acute Admission


Acute MI within 7 days post surgery


* Results generated by Signature Medical Group from Medicare claims data.


There are numerous examples of patients getting connected to nutrition counseling, mental health professionals, specialists, and primary care providers because their surgeon and case manager coordinated their care prior to elective total joint surgery.

As a result of participating in BPCI, physicians are changing their thinking and implementing new approaches to patient care by actively managing patient risk factors and comorbidities prior to surgery. Case managers are conducting clinical risk assessments about four weeks prior to surgery and this new process is an essential component of care. Patient optimization is becoming the new standard of care in orthopaedic bundled payment initiatives and our system and patients are better for it. 


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About the Author

Ann Conrath, MSW, LCSW is an Account Manager at Signature Medical Group, Inc. (SMG) a multi-specialty physician group with nearly 150 physicians in 17 specialties primarily located in St. Louis and Kansas City, MO. Conrath has worked in several capacities within the healthcare field, including political advocacy, community organizing, research, and direct patient care. In her current role at SMG, Conrath has worked to create, structure, and implement several value-based care initiatives, including maternity care home models and orthopaedic bundled payments. SMG is the largest orthopaedic convener for the Bundled Payments for Care Improvement (BPCI) initiative and Conrath actively manages ten orthopaedic groups in the Southeastern region to improve patient outcomes, reduce unnecessary medical expenses, and maximize financial opportunity in this government value-based program. She is dedicated to improving the alignment between financial incentives and quality care within our healthcare system.

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