5 Ways to prepare for CJR

The Center for Medicare and Medicaid Innovation's (CMMI) new bundled payment model, Comprehensive Care for Joint Replacement (CJR), will begin on April 1, 2016. The model requires mandatory involvement of hospitals in 67 Metropolitan Statistical Areas (MSAs).

Beginning in year two of the model (episodes with an acute care admission on October 1, 2016 or after), these hospitals will be at financial risk for the total cost of all Medicare lower extremity joint replacement (LEJR) surgeries. Hospitals need to manage the entire episode of care for these patients from three days prior to hospital admission through 90 days post-discharge (or 120 days if post-episode spending is considered).

It's true that CJR is a complicated model and requires major adjustments within most hospital systems. So where should hospitals begin? Here are five ways to prepare for CJR.

1. Assemble a CJR Team
In order to achieve success in bundled payments and CJR, it takes a village. A variety of talents are required to implement a model of this magnitude. Does a participating hospital have people to manage patient cases, implement IT strategies, analyze data, align stakeholders, work with the Centers for Medicare and Medicaid Services (CMS), and drive strategic decisions?

Hospitals need to evaluate their ability to fulfill the roles and responsibilities needed to successfully implement CJR. Which staff members need to be an integral part of planning, implementing, and managing the model? Evaluate current workloads and decide if internal staff duties can be rearranged, or if more staff needs to be hired. If new staff needs to be hired - do not delay. Allow time for proper education on the details and complexities of CJR. Perhaps most importantly, a model such as CJR needs someone at the helm. Who is the CJR leader?

2. Establish Provider and Consultant Partnerships
A critical partnership to establish is with orthopedic surgeons. Surgeons are the ones who establish initial patient relationships, establish initial care pathways, and have significant influence on necessary post-acute care. To succeed in CJR, care protocols should be standardized throughout the entire episode. Hospitals need to develop a strategy to align their CJR goals, strategies, and incentives with orthopedic surgeons, regardless of whether the surgeons are employed by the hospital or are from independent practices.

Post-acute care providers are also an important part of a patient's care plan as associated charges are included in the bundle within the 90 day post-discharge period. It is important to identify high quality downstream providers that understand the goals of CJR and are willing to work with the hospital to co-develop and implement care protocols for LEJR beneficiaries consistent with the goals of the CJR model. Hospitals should start building such relationships and expectations now.

While partnerships with orthopedic surgeons and post-acute care providers are clearly essential, other partnerships may seem optional (although I would argue they are just as important). Should a hospital not have the internal capacity to implement all aspects of CJR (requiring outsourcing of certain job responsibilities), now is the time to evaluate and determine efficient suitable solutions. Hospitals may need to establish contracts for:

• Data analytics
• Care navigation solutions
• Strategic consultants to:

  • Establish protocols and manage spending
  • Create engagement and alignment among doctors, case managers, administrators, and clinical team

Now is the time to locate and vet potential partners. How is this done?

3. Release a Request For Proposal (RFP) or Request For Information (RFI)
Once a hospital has decided they need some outside help, such as consultants or third-party providers, an RFP or RFI should be crafted to find the best collaborators. An RFP or RFI needs to be specific, describe exactly what is needed, and be written with carefully crafted questions that elicit relevant responses from top performing partner organizations. A hospital wants to find partners who can provide the specific services it needs and who will become an asset to the team.

Once an RFP or RFI has been crafted and released, RFP and RFI submissions need to be reviewed to identify the best partners for CJR success. For any potential partner, hospitals need to make sure the partner brings expertise and the capacity to work with the hospital's specific needs, and has an experienced team to bring the services, insights, and analyses required. While there may be many new businesses popping up to fill this service gap, CJR hospitals should strongly consider partners with a proven track record of engagement and success in administering necessary services in other CMS bundled payment programs.

4. Quality Measures – What is the hospital's current and historical score?
Evidence of quality care is required by CMS and scores on two quality measures impact the amount of reconciliation payments received regardless of whether hospitals are able to stay under their designated target prices. The two quality measures relate to complication rates and patient experience. A third voluntary measure evaluates patient-reported outcomes. The measures are combined into a composite quality score that determines repayment eligibility and the discount rate applied to the target price by Medicare.

In order to be in a position to receive the best possible financial outcome in the CJR model, hospitals need to ensure their quality scores are top notch and strategies to begin improving upon these measures should be implemented sooner rather than later.

5. Request Hospital Data
According to the final CJR ruling, hospitals do not receive data unless it is requested. The mechanism for requesting data from CMS is still being worked out. Once available, hospitals should act quickly to request historical data and be prepared to analyze this massive data set. Analysis of the historical data set is the first step to gain insight into a hospital's financial risk as well as to begin strategizing and planning how to manage service utilization to eliminate waste while providing quality patient-centered care. The data serve as the driver to assess acute and post-acute care utilization patterns and provide a foundation for determining historical episode costs.

Hospitals need to move rapidly to implement the aforementioned processes in order to assess potential financial risk and opportunities to provide quality care while decreasing cost within this new healthcare payment model.

Since data analytics is such a significant component of CJR, I will be releasing a more in-depth article about this topic in the next few weeks.

Follow me on Twitter @jimgera, connect with me on LinkedIn, or contact me at SMGBundles@signaturehealth.net for more information or assistance in working with data or in implementing the CJR model.

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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