Up until now, CMS has been experimenting with a number of different, voluntary payment models focused on two areas: accountable care (e.g. Pioneer ACO models, Next Generation ACO, Nursing Home Value-based Care) and episode-based payments initiatives (e.g. BPCI, Oncology Care Model). The Comprehensive Joint Replacement (CJR) model will quicken the pace by mandating an alternative payment model, which will widely affect the industry by April 1 of this year.
Why CJR?
Hip and knee replacements are fairly common procedures with extremely variable costs across the country, per provider, per episode. Accounting for over $7 billion in CMS spending each year, CJR is intended to reduce the costs associated to these procedures while maintaining quality outcomes. Healthcare providers will also be incentivized to work together during lower extremity joint replacement (LEJR) episodes, as they will be held accountable for care quality and spending. At the end of each year, CMS will assess all claims for episodes in each hospital in order to determine the reconciliation payment owed to the hospital or the repayment amount owed by the hospital.
Measuring Quality and Satisfaction
CMS built quality and satisfaction measures into the CJR framework, which will affect the amount of reconciliation or repayments hospitals will have. The framework uses standard National Quality Forum (NQF) endorsed measures for hip and knee replacements surgery, including whether any particular complications outlined in the rule should arise during an episode. CMS is also evaluating patient satisfaction and HCAHPS (Patients’ Perspectives of Care Survey) scores, focusing on hospital staff communicating with patients while in the hospital, especially regarding post-discharge issues.
“Don’t Fumble Your Bundle”
Based on CMS’s experience with the various Bundled Payments for Care Improvement models, especially LEJR, the CJR initiative will likely drive significant change across the healthcare landscape as hospitals and their collaborators work to share best practices while they undertake the mandatory management of patient risk.
How to prepare
1. Evaluate orthopedic surgeons’ efficiency opportunities, such as procedure specialization, physician time maximization at the hospital and alternative procedures with shorter recovery time.
2. Work with orthopedic surgeons to evaluate options for discharging patients to lower acuity of care settings, including new telehealth advancements and options for patient engagement.
3. Review quality status (CMS star ratings) and efficiency as they relate to CJR patients. These are key elements for hospitals to seek post-acute providers to manage CJR patients. Some hospitals will be incented to bypass SNF stays, when possible.
4. Home health and care management will be critical to the success of the CJR initiative for patients post-rehab.
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