The post-acute care providers' guide to the Comprehensive Care for Joint Replacement Model

CMS declared lofty goals in January when it announced its plan to shift 30 percent of all Medicare payments to value-based models by 2016. By 2018, the benchmark is to have half of all Medicare provider payments fall under an alternative model, which includes accountable care organizations, patient-centered medical homes or bundled payments. In July, CMS showed it was serious about the transition when it announced the Comprehensive Care for Joint Replacement (CCJR) Model.

Under the five-year CCJR program, hospitals would continue to be paid according to existing Medicare fee-for-service payment rules. However, the hospital where the surgery takes place will be held accountable for the quality and costs of care from the time of surgery through 90 days after discharge.

The CCJR Model would initially be implemented in 75 geographic areas and, unlike other existing bundled payment programs, the CCJR Model would be mandatory for hospitals in those areas that perform lower extremity joint replacements.

Like acute care hospitals, post-acute providers cannot opt out of the program. If a post-acute care (PAC) provider treats a patient that is part of the CCJR program, then the PAC provider becomes part of the program and part of the total spending the hospital is going to be responsible for. This makes post-acute care providers a key player under the CCJR Model, according to a webinar sponsored by the DataGen Group, which provides customized data analysis to healthcare organizations.

During the webinar, three experts from DataGen discussed the CCJR program from a PAC provider's perspective, including the following seven things every PAC provider should know about the model.

1. All the spending variation is in the post-acute setting. Under the program, Medicare spending for the inpatient acute stay is not variable. "Because this is a DRG bundle, every single anchor admission costs CMS the same amount of money," said DataGen Senior Director Kelly Price. However, there is variability in post-acute care spending, which means all of the reduction in spending hospitals are trying to achieve is going to have to come out of the post-acute setting.

2. Meaningful outcomes measures currently do not exist. The CCJR program includes three quality metrics: patient satisfaction (HCAHPS scores), total hip and total knee replacement readmissions and total hip and total knee replacement complications. According to DataGen Principal Analyst Alyssa Dahl, there are currently no meaningful outcomes measures, such as a standard, national measure for days to full recovery or patient satisfaction, across the entire episode of care. However, PAC providers need to find ways to stand out. "Hospitals are going to be looking at downstream providers to show their readmission and complication rates are lower than others," said Ms. Dahl. Although PAC providers have a pretty good idea of how their patients do in the end, tracking outcomes and having that data available is extremely valuable.

3. Readmissions are the most significant cost driver. Under the CCJR Model, readmissions to acute care facilities count toward the readmissions quality metric. According to Ms. Dahl, a readmission alone adds expense, and post-acute spending for patients with a readmission tends to be higher as well. This additional spend under the CCJR program can be avoided, as almost all causes of readmission after joint replacements are avoidable. To succeed in the program, PAC providers need to address the issues that are causing their patients to be readmitted and prove their value by showing the steps that are being taken to reduce infections and complications.

4. Inpatient rehabilitation facilities are the most expensive PAC setting. Inpatient rehabilitation usually costs a few thousand dollars more than care in a skilled nursing facility (SNF), and some inpatient rehabilitation patients still step down to a SNF or home healthcare, according to Ms. Dahl. Although inpatient rehabilitation facilities are the most expensive PAC setting, they might be in a better position than other care settings to reduce complications and readmissions post surgery, said Ms. Dahl.

5. SNF length-of-stay is another significant driver. There are two main drivers of cost of care in the SNF setting: case-mix and length of stay. Case-mix really can't be controlled, so the focus needs to be on the length of stay component. SNF reimbursement is on a per diem basis so the cost of care is incrementally increasing with each day the patient is in the SNF. There also appears to be a strong correlation between SNF length-of-stay and readmissions, as readmission rates are increasing the longer a patient stays in a SNF, according to Ms. Dahl.

6. Bundled payments provide opportunities for non-conventional strategies. To generate savings, many hospitals are putting together a team to meet with the patient prior to surgery to set expectations as to what their post-acute care will be, according to DataGen Vice President and Chief of Healthcare Analytics Gloria Kupferman. "They make sure they [the patients] have all of the support possible in place. Or, if the support isn't there…those supports can be provided," she said.

Another non-conventional strategy is inpatient acute facilities keeping patients a little longer to start the rehabilitation while they are in the acute setting, which allows patients to go home instead of to a post-acute provider. "This opens the door for the use of telehealth in a more meaningful way," said Ms. Kupferman. If the patient is afraid to go home because they want to be in touch with a caregiver, telehealth can give a patient security in going home.

"There are a lot of interesting and new ways to approach helping people get home sooner, which is what everybody wants, including the patient usually, because everyone gets better sooner in their home if they have the right support," said Ms. Kupferman. However, she emphasized there is no incentive for PAC providers to do any of this unless they get a share of the savings from the episode owner.

7. Know your value. "Every provider has a story," said Ms. Dahl. Some providers have much higher SNF spend and some have more money going toward readmissions than others, but it is vital providers understand their strengths and weaknesses. Low-cost PAC providers are automatically going to stand out in the CCJR program, while high-cost providers will need to show they're producing better outcomes to justify the additional cost, according to Ms. Dahl.

To learn more about how to be a successful partner in CCJR, click here. 

To learn more about the post-acute care provider's role in the CCJR program, view the full webinar on YouTube here. View archived webinars here.

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