4 Steps to maximize reimbursements under Medicare's CJR initiative

Medicare's Comprehensive Care for Joint Replacement Model (CJR) is coming up on a full year of implementation for the 67 markets where it has been activated.

Providers operating under the model are beginning to stratify into two distinct groups: those that have appropriately downsized risk and improved outcomes and those that are still figuring it all out. According to healthcare consultancy Avalere, 60% of the 800 hospitals impacted by CJR are incurring costs that are higher than regional and historic benchmarks -- these providers are going to find themselves digging out of holes once performance becomes directly tied to reimbursements.

This matters for all hospitals, not just those performing joint replacement surgeries. That's because CJR is a harbinger of things to come. It's one of Medicare's initial forays into value-based reimbursement, but it is expected to aggressively move additional programs to the model in the upcoming years. Aetna, Blue Cross Blue Shield and Cigna are also initiating their own bundled payment programs that share similarities with CJR, and most or all of the major private payers are likely to follow suit as they seek to control costs and optimize member satisfaction rates.

How can a hospital align itself with the value-based care model while continuing to deliver positive outcomes across the spectrum of its patient population? Placing the patient and outcomes at the center of everything while controlling costs can seem tricky, but mastering these four operational tenets will ensure survival in Medicare's new CJR universe as well as whatever value-based or bundled reimbursement plans payers come up with in the future.

1. Develop multidisciplinary care teams.

Bundled payments provide reimbursements to hospitals as well as pre- and post-surgical care providers simultaneously. Since reimbursement is based on outcomes, each stakeholder shares a vested interest in ensuring the best possible outcome --but they are still independent entities that are focused on their own individual aspects of care. Tracking the performance of the entire care team and patients on their journeys through the episode falls onto the hospital, with each stakeholder relying on the others to deliver results that contribute to positive outcomes. If the right hand doesn't know what the left is doing, optimizing outcomes is unnecessarily complicated.

2. Manage patients along flexible care pathways.

It is vital to give every stakeholder the ability to adhere to evidence-based care pathways that are developed for each patient. Observing, documenting, and monitoring patients as they travel down the path is critical to generate the best outcomes and maximum reimbursement. A CJR pathway should include pre-surgical patient risk assessment, patient and caregiver education, and tools to collect Patient Reported Outcomes to obtain CMS bonus payments.

Keeping the care process running smoothly is dependent upon tracking the performance of each team and each individual member. Each stakeholder must have insight into what the others are doing while also maintaining the autonomy to manage their own task lists, set reminders, and see when patients are set to receive outreach or need intervention. For this reason, it is best when every member of the care team is using the same technology platform to track the entire patient episode. A shared platform takes advantage of the aggregated specialty knowledge each role provides while creating workflow efficiencies that enable better adherence to evidence-based care plans, simple communication of care plan adjustments, and less chance for human error.

Even in an evidence-based world, expect and allow diversity in the care plan; each one should be specialized based on the patient's specific medical, social, and lifestyle needs. As the patient progresses, changes to the plan may become evident. Giving every member of the care team the ability to alter the care pathway in a way that is visible to all others eliminates confusion and keeps everybody on the same page so all subsequent touchpoints are synchronous with any deviation from the original path. The best care pathways work with existing IT infrastructure and updates plans in real-time to reflect any changes made in the EMR, eliminating redundant data entry and keeping every care provider armed with the most recent changes to the care plan.

3. Keep patients the center of the process from end-to-end.

All caregivers activated in a patient care episode have shared responsibility to deliver a cohesive and streamlined experience. The goal is to provide a concierge-style patient experience, and that requires that all stakeholders stay connected throughout the entire care plan. It's easy for information to fall into gaps between referring providers, surgical care teams, and post-surgical care providers, which is why it is vital that they are all continually updated on care progress.

It starts with pre-operative patient education and continues with engagement throughout the entire episode, not ending until a positive outcome is realized. Sharing data for every patient experience not only optimized outcomes for those individual patients, it also identifies meaningful trends in performance data for aggregated experiences. Keeping referring providers in the loop with secure email helps boost provider satisfaction keeps the patient from believing that continued advocacy is necessary to ensure quality care. The perceptions patients have on the care they are receiving can have a very real impact on the outcomes that they achieve and that affects reimbursements.

4. Manage readmission risk with improved patient engagement.

Approximately 40% of Medicare episode payments are related to post-discharge care. That makes post-surgical management the area where the most financially impactful results can be achieved. One of the fastest ways for costs to spiral out of control is through hospital readmissions, but there is a lot that providers can do to prevent this. It is all centered on patient engagement that begins with patient education from the start and collecting detailed information during the onboarding process that assesses needs and risks. Patient engagement throughout the process keeps these needs and risks updated and advises what education they should be provided to empower them to manage their own recoveries and prevent complications.

High-risk patients should be targeted with specific interventions to keep them on track and identify problems early. Daily surveys can both keep patients engaged in their own recoveries and provide care teams with updated risk levels in real-time to target the patients at highest risk of readmission. Complications that are intercepted before they lead to readmission result in higher satisfaction rates, better outcomes and lower costs. Understanding the inverse correlation between engagement and readmission helps achieve the best reimbursements in value-based models.

High levels of patient engagement are key to keeping costs at bay, but communication between stakeholders is an important precursor to achieving it. Value-based reimbursement models reward a team approach to care where information and results are shared freely between providers and changes in the care plan are recorded and reflected in real-time. Optimizing reimbursement in CJR and similar models is best achieved through streamlining communication and tracking across caregiving teams with technology that is specifically designed to do so while integrating with existing EMR platforms.

John Richmond is the CEO at Sequence Health, a performance-optimizing healthcare technology and service company focused on helping bridge the communication, education, and participation gaps within the patient-provider relationship.

The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker's Hospital Review/Becker's Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.

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