Could A Toilet Aid Help Reduce Costs For Medicare Joint Bundle Payments? April 22 2016


In 2014 about 400,000 hip and knee replacement surgeries were performed in 2014 costing about $7 billion. (Feller) The new Medicare rule that started April 1, 2016, would shift spending by introducing bundled payments, which  Medicare estimates the program will save $343, Million.  800 hospitals were mandated by Medicare and Medicaid services to participate in bundled payments for hip and knee replacements. This new bundle payment rule for hip and knee replacements will hold hospitals accountable for all costs of surgery for up to 90 days. Hospitals will be reimbursed by Medicare using the regular payment system, what changes is at the “end of each “model year” actual facility spending will be compared to the Medicare target prices. Based on “quality and episode performance,” they receive an additional payment or have to repay Medicare a portion of spending.”(Medline Plus)

The goal of this bundle payment rule will be to make hospitals more accountable for infections and implant failures. Currently, for knee and hip replacements the average cost of surgery can range from $16,500 to $33,000 depending on location.  The success of this rule will be key to hospitals working more closely with doctors, home healthcare providers, and other care providers to coordinate how best to serve a patient’s needs.(Beck)

Benefits of Bundles

  • Eliminate inefficiencies
  • Prevents Duplication of Effort
  • Improves Documentation of Patient Care and Recovery
  • Reduces Hospital Stays
  • Reduces Surgical Complications
  • Lowers Re-Admission Rates

How Have Hospitals Changed?

With these new changes, hospitals are now creating initiatives to align reimbursement with improving health, improving care, and reducing total costs. The ultimate goal for incorporating bundle payments should be improving patient health by delivering the right services to the right patients at the right time.(Ciarametaro)

For example, CHI St. Alexius Health in Bismarck, N.D. prepared for the bundled payments for joint replacements by implementing the following

  • Educating and preparing patients and families
  • Conduct pre-surgery assessments
  • Engage surgeons, anesthesiologists, nurses, and physical therapist and to improve clinical processes to reduce complications, length of stay, pain, and referrals to post-acute-care providers
  • Consider hiring nurse navigators to focus on pain management
  • Develop a preferred network of high-quality post-acute-care providers

Since March 2015 CHI St. Alexius Health, has cut average length of stay from 2.5 days to 1.7 for knees and from 2.6 days to 1.79 for hips and it is sending only about 8% of patients to skilled nursing or rehab, compared to the 30% they were sending back in 2010.

Richard Bajner, managing director at Navigant Consulting’s healthcare practice who helped Baptist set up the program’s infrastructure where 43 surgeons were to participate in the bundles; he mentions that they were very skeptical. However, they ended up creating the following

  • Physician groups
  • Representative Boards
  • Treatment Protocols
  • Supply Chain agreements
  • Care pathways
  • Focused on post-acute market

By understanding the marketplace better they could better engage within the market.  He says the biggest savings in all the bundles has come from moving away from heavy SNF utilization. Mobilizing home health to help patients stay in the home has been a big satisfier for them—and also a big money-saver. (Betbeze)

Not All Treatment Should Be the Same

Bundle payments should also allow for variations in a patient care and not use a “one-size-fits-all” model because patients may not receive all they care they need. Healthcare is increasing with new technologies that can help patients, but what about basic daily tasks such as toileting and personal hygiene care. Doctor care instructions for a person after knee surgery states “do not twist or pivot your body…”(6).  Would you prefer to have someone else take care of your toileting and bathing after hip or knee surgery or would you prefer to do it yourself?

Currently, about half of hip and knee replacements patients spend time in a skilled-nursing or rehab facility, which increases costs. What if they added a toilet aid to the pre-surgery class, care pathways or even just talked about it to let patient’s know that they have the option of doing it themselves vs. a family member, spouse, or a caregiver.

 Would this increase patient satisfaction & confidence?

Would this decrease the length of stay in rehab or the hospital?  

Would this reduce patient infections?




Beck, M. (2016, April 1). Hospitals Brace for New Medicare Payment Rules. In The Wall Street Journal . Retrieved April 20, 2016, from
Betbeze, P. (2016, March 22). Get Comfortable With Bundles. In Health Leaders Media . Retrieved from
Ciarametaro, M., & Dubois, R. (2016, April 20). Designing Successful Bundle Payment Incentives . In Health Affairs Blog. Retrieved April 20, 2016, from
Evans, M. (2016, March 26). Knee and hip bundled-payment challenge is about to start. In Modern Healthcare. Retrieved April 20, 2016, from
Feller, S. (2016, April 1). New Medicare model may improve care, cost for knee, hip surgeries. In Health News . Retrieved April 20, 2016, from
Knee joint replacement - discharge. (2014, November 26). In Medline Plus. Retrieved April 20, 2016, from