In part 2 of Demystifying CJR for Healthcare Providers, we previously discussed the waivers and incentives implemented by Medicare that allow more flexibility for treating patients under the Comprehensive Care for Joint Replacement Model (CJR). In this final post, we will go over some of the solutions healthcare providers and hospitals may consider in order to deliver efficient care, enhance patient satisfaction, and help patients obtain the best outcome possible under CJR.
In traditional Medicare Fee for Service, payments to the provider are based on each service furnished to the beneficiary during a particular course of treatment. As a result, the payment amount becomes dependent upon the volume of services delivered; placing little incentive to pay attention to both the quality and efficiency of care beyond hospital discharge. This creates a propensity for a fragmented episode, which can lead to decreased patient satisfaction, increased patient episode spending, or unnecessary care. Part of this is evident in the cost variability for total knee and hip replacements which can range from $16,500 to $33,000 in geographic areas.
The mean estimated Medicare payment is roughly $26,000 where approximately 55% of that spending comes from inpatient services, 25% from post acute care services, and 20% from physician and other outpatient spending.
CJR places the acute care hospital at the center, making them the episode initiator responsible for the outcomes and costs of care from admission through 90 days post discharge. By doing this, Medicare believes CJR will give the hospital incentive to explore new care models that will democratize the process of healthcare delivery for beneficiaries undergoing a joint replacement procedure. As such, healthcare providers can expect acute care hospitals to invest in care redesign processes that will focus on the following:
1. Care Coordination
Each setting will have to work closely with the hospital and clearly identify the roles and responsibilities of the clinical staff during a beneficiary’s transition through the post acute spectrum (inpatient, skilled nursing, home health, outpatient, etc). By establishing continuity of care between services, there will be less likelihood for duplicative care. There will also be more incentive for the beneficiary to stay on the participant hospital’s care pathway rather than going to another hospital or health system.
2. Patient Education and Expectations
The hospital and healthcare provider will likely place greater emphasis on patient education and expectation setting in an effort to encourage beneficiaries to play an active role in their own recovery. This can involve:
- Preparing the home prior to surgery in order to reduce the chance for falls or accidents
- Setting expectations early and educating beneficiaries on the surgical and post acute care processes to reduce patient uncertainty
- Informing patients on potential complications and specific actions to take should they occur
3. Patient Communication and Monitoring
Since they are now responsible for patient outcomes, the hospital will likely take advantage of the several CJR waivers such as the telehealth and patient engagement incentive waivers. This will allow healthcare providers to maintain control of the patient episode and gain more access to the beneficiary’s recovery once they go home. And since many of the CJR waivers focus on enabling care in the the beneficiary’s place of residence, health care providers can expect the hospital to implement new technologies or processes that will monitor the patient’s adherence to their care plan and increase overall accessibility so as to encourage improved patient-provider communication.
As part of care redesign, hospitals may make changes to their care pathways and how they transition patients through post acute care. For example, healthcare providers may transition patients sooner from an inpatient rehab facility (which tend to be higher in costs) to a skilled nursing facility (SNF). The SNF 3 day waiver makes this possible for healthcare providers who may recommend discharging patients to a SNF in less than 3 days. Under traditional fee for service, discharge patterns to a SNF have been relatively high. However, under CJR, hospitals and healthcare providers may increase their patient disposition directly to home health and/or outpatient physical therapy, bypassing skilled nursing or any other length of stay facility if it is appropriate to do so. This can make risk stratification processes, such as utilizing the RAPT score sheet, an integral component of discharge planning and preparation for postoperative recovery.
But the hospital and provider must also take measures to ensure quality outcomes are achieved. In addition to cost savings, the CJR hospital is also on the hook for ensuring good patient outcomes and minimizing patient complications. Under CJR, Medicare will be looking at the following measures to determine the hospital’s quality score and target price:
- Hospital level risk-standardization complication rates (RSCR)
- Hospital consumer assessment of healthcare providers and systems survey (HCAHPS)
- Patient reported outcomes (PRO’s) such as the hip injury osteoarthritis outcome score (HOOS) and knee injury osteoarthritis outcome score (KOOS)
So while there may be incentive to reduce inpatient stays, the hospital and physician must utilize their clinical judgement to carefully determine the medical appropriateness of early discharge. Episode spending can dramatically increase should any complications or readmissions occur during the patient episode; thereby, increasing the hospital’s chances for a financial penalty.
Hospitals will have to carefully consider the post acute care providers they partner with. To achieve positive patient outcomes along with greater efficiency, these post acute providers must not only be in financial alignment with the participant hospital, but they must also possess the proper care redesign infrastructure and technology in order to deliver outcomes based care to patients within a risk based payment model.
Leverage Digital Health Technology
Digital health technologies can serve as an attractive solution for healthcare providers and hospitals that seek to innovate the post acute care continuum. Technologies that leverage remote monitoring and telehealth have potential to extend the provider’s reach beyond the in-clinic setting and into the patient’s home. This gives them more objective insight into the effectiveness of the care provided, enabling them to make more informed clinical decisions. Additionally, by utilizing digital health technology, the provider can potentially treat more patients and do so effectively.
These technologies can also enhance patient engagement and promote patient adherence to care programs at home, which are crucial to an effective joint replacement recovery. Clinicians can also utilize these technologies to safely determine which patients will be in most need of their care. A recent study in the Journal of Telemedicine and Telecare revealed that clinical outcomes for postoperative tele-rehabilitation was equivalent to traditional care and demonstrated lower outpatient utilization following total knee arthroplasty (TKA) patients.
It is a clear signal of an accelerated transition from volume to value, with Medicare creating greater incentive for hospitals to integrate both acute and post acute care services.
Traditionally, most acute care hospitals have paid little attention to the patient’s recovery once the patient leaves the hospital. But that mindset will have to change quickly, given the CJR ruling and other new payment models that CMS has implemented. It is a clear signal of an accelerated transition from volume to value, with Medicare creating greater incentive for hospitals to integrate both acute and post acute care services. Healthcare providers should take a proactive approach with CJR, and take advantage of its opportunities to define this new paradigm of care and ensure success of their patients. The full text of the CJR Rule is available in the Federal Register.
by Ben Torres