Amid uncertainty about how CMS might change its joint replacement bundled payment programs, hospital participants have been "impressed" with how the voluntary and mandatory models have engaged doctors in improving outcomes and lowering costs, Harris Meyer reports for Modern Healthcare.
CMS in August proposed rolling back the Comprehensive Care for Joint Replacement Model (CJR) bundled payment model, which has been in effect since April 2016, from 67 mandatory geographic regions to 34 mandatory regions. The agency in the proposed rule also underscored that they intend to unveil a new voluntary bundling program for 2018.
According to stakeholders, the financial incentive of meeting a fixed cost for a care episode encourages better communication among otherwise competing players, Meyer reports.
For instance, Henry Sullivant—VP and CMO for Baptist Memorial Health Care Corp., which has hospitals in the mandatory program, CJR, and the voluntary program, called Bundled Payments for Care Improvement (BPCI)—said in the past, "the competing interests had no incentive to sit at the table and take out inefficiencies." He added, "The wonderful thing about this type of program is it puts us all at the table together solving issues collaboratively."
Separately, Andy Tessier, director of business development for the Signature Medical Group, said, "These programs are forcing physicians to look holistically at the patient for an entire episode." He added, "What I'm hearing is they are making these specialists better doctors."
Modern Healthcare reports that some stakeholders are concerned that CMS' proposal to roll back CJR would reduce such incentives for collaboration. Meyer reports that these stakeholders hope HHS will retain and expand the BPCI program.
For instance, Amol Navathe, an assistant professor of health policy and medicine at the University of Pennsylvania, said, "I do worry if we dial back these programs and don't replace them with additional programs, we could lose a lot of momentum we've never seen before in transforming care."
Collaboration in action
According to Meyer, care coordinators and providers associated with several hospitals and health systems have reported success with the programs by involving physicians and effectively utilizing data.
For instance, after Piedmont Athens Regional Medical Center was mandated to participate in CJR, Executive Director of Operations Geoffrey Cole sat down with surgeons from two local orthopedic groups and reviewed utilization and cost data. From that assessment, they learned that roughly half of joint-replacement patients went to skilled-nursing facilities or rehabilitation after the procedure—a trend that could threaten Piedmont Athens' ability to meet the bundled price target and "did not necessarily produce the best outcomes," Meyer writes.
To tackle the issue, the surgeons worked to minimize such referrals, cutting use of post-acute facilities for joint-replacement patients from about 50 percent of cases to just about 10 percent. According to Cole, surgeons appreciated the improved outcomes and lower costs, and they are engaged, cooperative, and are bringing more patients to the hospital. Medicare recently rewarded the hospital with a a $107,000 bonus for meeting its quality and cost targets under the program—and Piedmont Athens plans to remain in the program next year, even though HHS said it may be voluntary for hospitals in the Athens region.
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Separately, Monica Deadwiler—senior director of financial product innovation at the Cleveland Clinic, whose hospitals participate in BPCI for joint replacements—emphasized the importance of choosing the right physician leaders when redesigning care to align with bundled payments.
Cleveland Clinic initiated its work in BPCI at Euclid Hospital in 2011, under the guidance of the hospital's president, who was a physician. And after the model went in live in 2013, the Clinic made a few adjustments, detailed the model in a "playbook," and worked with physician leaders at other hospitals to tweak the care redesign at each location. Specifically, at each hospital, the physician leaders would meet with other doctors and clinicians involved in joint replacements and talk through potential process changes, providing physician support throughout.
Meanwhile, at Signature Medical, Tessier said the physicians they consulted with often hadn't previously seen detailed post-acute utilization and spending data and generally didn't know much about the patients' trajectory after surgery—and seeing that information for the first time was eye-opening.
"It's a process of getting the doctors in a room and looking at the data together," Tessier said. "It's not telling the doctors what to do. It's being the moderator so they can make evidence-based changes to their practice."
In addition, helping surgeons prepare patients and families for surgery and recovery is "another key to … success" when it comes to bundled payments, Meyer reports. Such efforts involve helping patients take actions—such as quitting smoking or losing weight—that can improve surgical outcomes. To address this, several orthopedic surgeons, including DMOS Orthopaedic Surgeons in Iowa, have hired nurse practitioners or surgical assistants for patient education (Meyer)
Upgrade your joint replacement pathway for CJR
The Comprehensive Care for Joint Replacement (CJR) model is CMS’s first mandatory bundled payment program. It holds hospitals accountable for managing outcomes across a 90-day episode of care for two common Medicare inpatient surgeries—hip and knee replacements.
Consider these five strategies to reduce variation across the joint replacement care episode, and then access our Joint Replacement Pathway Toolkit to find implementation guidance and resources.