Under value-based payment models, healthcare providers are rewarded for care that produces the best possible outcomes for the lowest possible cost. Bundled payments, which pay providers a set amount for an entire episode of care, are central to such systems. In a bundled payment model, providers are responsible the patient from pre- to post-operative care, and either share in savings or absorb the extra costs associated with complications, extended length of stay or readmissions. Because of this, providers are financially motivated to redesign clinical pathways and enhance coordination to ensure the best possible outcomes.
The Comprehensive Care for Joint Replacement Model, which took effect April 1, is CMS’ first mandatory bundled payment model. This program focuses on hip and knee replacement, and it applies to about 800 hospitals in 67 markets across the U.S. During the five-year program, CMS’ fee-for-service rules still determine hospitals’ payments. However, at the end of each performance year, CMS compares a hospital’s spending for a care episode to the target episode price. An episode begins when a patient is admitted to surgery through 90 days post-discharge, including care in inpatient rehabilitation hospitals or skilled nursing facilities.
Depending on the participant hospital’s quality and spending performance, the hospital may receive an additional payment from Medicare or be required to repay Medicare for a portion of the episode spending.
The CJR Model and other bundles are greatly influencing the way providers must approach the episode of care. Clinicians must be prepared to make significant changes, including expanding care teams, using data to monitor performance against financial targets, structure post-acute networks and provide feedback to physicians.
Kelly Price, vice president and chief of healthcare data analytics at DataGen, will go over these learning points and more during a Nov. 16 webinar sponsored by DataGen and hosted by Becker’s Hospital Review.
To register for the webinar, click here.
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