The Future of Virtual Therapy within the CJR Bundled Payments Model of Care

Welcome to Part 2 of our interview with Dr. Frank Aluisio, accomplished orthopedic surgeon and co-founder of Valere Bundled Payments.

There’s little doubt that, with the CMS’ recent push to expand bundled payments reimbursements as demonstrated by the Comprehensive Care for Joint Replacement (CJR) program, this new model of care represents in no small part the future of healthcare delivery in America.

As a middle ground between fee-for-service and capitation models, the bundled payment system has been widely recognized as a key driver in reducing costs while improving quality of patient care. And studies are increasingly backing up these claims.

“During a period in which Medicare payments for joint replacement episodes increased by 5%, bundled payment for procedures at BHS [Baptist Health System] was associated with substantial hospital savings and reduced Medicare payments,” concluded the authors of a JAMA Internal Medicine study published in February 2017, emphasizing that the decrease in post-acute spending “occurred only when it was included in the bundle.”

Bundled payments offer physicians “a chance to make healthcare better, faster and cheaper,” as we reported here at the Reflexion Health blog back in 2015.

“For years, physicians have believed that if only a creaky, bureaucratic payment system got out of the way, they could deliver much better care and a better experience for less cost to the system. CCJR gives joint surgeons and their team a chance to prove it.”

Medicare’s CJR Bundled Payments Model: Where Virtual Physical Therapy Fits In

Based on their experience in the BPCI program — which is essentially the physician-run counterpart of the CCJR program — a group of four orthopedic surgeons in Greensboro, North Carolina seized the opportunity to pursue this vision, creating Delta Orthopaedic Management, a new type of physician-run outpatient joint care practice based on the bundled payments model.

The results were so positive that the group then formed a consulting company, Valere Bundled Solutions, to help others develop and manage similar programs to successfully provide outpatient arthroplasty bundled care.

Though still in its relative infancy, their program has already achieved striking results. “In our first year, we did more than 100 bundles with fantastic results,” one of Valere’s founding physicians, Frank Aluisio, MD, recently told us. “The level of patient and surgeon satisfaction was tremendous. We had zero hospital readmissions, and no significant complications.

“It’s a whole new avenue of medicine,” he added. “It’s probably one of the first things ever that will simultaneously improve the patient experience, improve patient outcomes, and yet, operate at a far lower cost than what’s going on now.”

Read more here about how Dr. Aluisio and his team at Valere have pioneered a practice style that’s leveraging the bundled payments model to positively transform outpatient joint care.

Even before the CMS launched the CCJR initiative, Reflexion Health has been a staunch proponent of the power of bundled payments to positively influence joint rehabilitation care. Over the past decade, we’ve worked to innovate virtual therapy solutions that coordinate care on the bundled payment model between hospitals/surgical centers and preferred outpatient clinics or physician groups like Valere, while simultaneously offering reduced-risk solutions to payors.

And it’s becoming increasingly evident that these efforts are reaching fruition, with virtual physical therapy demonstrating an ability to improve care that’s poised to a play a major role in the brave new world of bundled payment solutions.

“Physical therapy is often a critical component of care for patients who have TKR surgery,” stated Janet Prvu Bettger, ScD, Duke Department of Orthopaedic Surgery associate professor and principal investigator for VERITAS (Virtual Exercise Rehabilitation In-home Therapy: A Research Study). “Digital health technology, including virtual and telehealth options, may increase access, improve quality, and lower healthcare costs. Extending the reach of physical therapists into the home using a digital healthcare platform like VERA can provide remote guidance and supervision for a home-based therapy program.”

Dr. Aluisio, who had his residency in orthopedic surgery at Duke University Medical Center, was also involved in the VERITAS study, of which he speaks in enthusiastic terms.*

“I was blown away by the results,” he told us. “I was skeptical going into it — how in the world are these patients going to get high-quality results without hands-on therapy? But I was so pleasantly surprised — not only by the results, but also by the patients’ satisfaction. They really felt accountable to do the exercises, and felt they played a more active role in their recovery.”

The study “showed that the outcomes were equally as good or even better using virtual therapy versus standardized therapy, and the patients’ satisfaction was extremely high,” he added.

“The interesting thing is that even patients who weren’t Internet savvy or computer savvy embraced the technology and did very well with it,” he said. “I think we had maybe just one person who, before entering the study, needed additional help with how to use it. But for the most part, these people really embraced the technology.

“I think patients were initially skeptical by not having hands-on sessions with a therapist, but once they had the introductory period and realized they could do it, and saw how they were progressing over the first few weeks, they really embraced it. They felt accountability. They knew that someone was watching, so they had motivation to do the exercises.”

Dr. Aluisio attributes that motivation to the monitoring present in virtual care. “I think the accountability is different, because in the traditional model, they’re at home, and nobody’s watching. Under these circumstances, the majority of patients are still going to do their exercises, but there is a subset who may not do their exercises if they’re not held accountable.”

“One of the beauties of virtual physical therapy is that we know the patients are doing it more frequently,” Dr. Aluisio said. “We’re getting real-time results, and if someone is lagging behind, we can intervene faster.

“At the same time, it’s nice to know that they’re not going totally unsupervised. There’s always a therapist that’s viewing their progress. And in our experience so far, the therapist has been great at getting back to us instantly. Our initial fear is that we would lose that feedback … but if anything, we’ve found that there’s even closer feedback with virtual therapy.”

How Virtual Physical Therapy Improves the Patient Experience

“We want to do anything that’s going to improve the experience for patients,” he told us. “Oftentimes, we’ve found that if patients can recover in their home setting with equivalent or better results, that’s something that we want to include. We feel that it improves value by maintaining or improving quality, while decreasing cost.”

Pointing out that the VERITAS study focused on Medicare patients, and thus, the elderly, he noted that “it was far more convenient for them to do the therapy at home as opposed to go out of their homes and find rides.”

Impressed with the study results, and with his own experience with Reflexion Health’s Virtual Exercise Rehabilitation Assistant (VERA), Dr. Aluisio is confident of its eventual success within commercial bundled payment models.

“I think it’s a great relationship that’s developing now with Reflexion Health and our group, and it’s something that we hope to explore further in the future, and I think it’s something that definitely has value in the bundled situation,” he said.

“Our initial phase of setting up outpatient bundles was just incorporating standardized therapy, because we had so many variables at play. But now that we’ve found our model to be a safe way to do outpatient arthroplasty, and patient satisfaction is high, we’re looking at ways to improve the value by providing the option of virtual therapy.

“Now that we’ve seen the effectiveness of virtual therapy … the next stage will be looking for further ways to improve the patients’ experience after the surgery.”

As a proponent of the movement to solidify post-acute treatment options under a bundled care model, Reflexion Health offers services that support this goal: Our VERA model helps payers expand their capacity to leverage bundled payment solutions in a low-risk way. Learn more here.

Dr. Frank Aluisio is a board-certified orthopedic surgeon and a team member at Greensboro Orthopaedics, with whom Reflexion has a working relationship.

Editor’s note: The full results of the VERITAS study have yet to be released; Dr. Aluisio is referencing early results that he’s seen as a study participant.