This month the Center for Medicare & Medicaid Services has the chance to push forward an innovative and game-changing rule regarding bundled payments for full hip and knee replacements. Many prominent medical societies, includingthe American Academy of Orthopedic Surgeons (AAOS) and the American Physical Therapy Association (APTA), have argued that they should take their time and delay – at least a year.
That would be a mistake. Regardless of what CMS does – or whether they fit inside one of the 75 geographies currently slotted for the program – it behooves every physician and health system performing joint replacements to move fast toward building a new model.
Under the proposed rule, as of Jan. 1, 2016, the payment structure for Comprehensive Care for Joint Replacement (CCJR) will expand Medicare’s experiment into bundled payments for hip and knee replacements. Seventy-five selected metropolitan areas will be included in CCJR, encompassing nearly 800 hospitals. This will approximate 10 percent of the national joint replacement market.
Medicare couldn’t be hinting more clearly at their new playbook. The next-generation Diagnosis Related Groups (DRGs) are coming, and fast – and for high-cost, high-volume procedures, it’s going to include the entire post-acute phase of the recovery.
Even if you practice in a community not directly impacted, make no mistake, this is the tipping point. Hospitals and doctors are moving aggressively to cut similar deals with commercial plans, because who wants to re-design care for a bundle for only a subset of their patients? Once that happens, both will be looking to expand nationally, and those who are left with their heads in the sand will be swamped when the tidal wave hits.
Here Are 6 Reasons Why It’s Time to Get Moving
1. Get Real. The current system is broken. An average of $12,000 to rehab a knee replacement? Ask patients who have traveled along the pathway of hospital, nursing facility, home health and PT whether they feel like they’re getting good value. Let’s be honest: The current joint replacement care pathway can be greatly improved by opening the lines of communication between all parties. There are too many players on the field and not enough collaboration between the various brick-and-mortar institutions. Up to now, all that inefficiency has looked like revenue to a lot of people. Not for long.
2. Who can’t find 2 percent? Medicare will pay hospitals 2 percent less than it has historically paid for the same procedure. Now is the time to analyze the frustrations and inefficiencies and pinpoint the various ways to optimize savings. Most people familiar with the care pathway have ideas about where changes can be made to increase efficiency and improve care. Let’s expand the tools in our current toolbox with technologies and services that allow for better communication and coordination of care and ways to deliver real therapy outside the traditional medical temples. And the incentive is in the right place. After the 2 percent reduction is reached, hospitals will receive reimbursement for extra savings achieved.
3. All upside …for now. During the first year of the program there is no risk. Medicare is waiving the payment owed to them for higher costs during the first year, giving providers plenty of time to work out the kinks. As of Nov. 1, there were 426 days to become more efficient. It’s time to get going.
4. Leverage digital medicine and telehealth. Innovation in mobile health, smart patient-focused software, telehealth and the smart medical home continues to accelerate. These concepts are changing how we fundamentally think about delivering care, so that it’s more effective, engaging and cost-effective. With telemedicine, the client care pathway increases and patients are more pleased with their experience overall.
This can help providers deliver better care, closer to patients, at a lower cost, while at the same time giving patients a concierge-like, highly engaging experience. Just because the other two groups in town may not be (publicly) racing ahead yet on bundles – watch as the competitive set grows, where informed patients travel to centers of excellence, which can now extend the catchment area of their care by using telerehabilitation services.
5. Patient benefits. A lot of the spending we see in joint replacements doesn’t have a lot of value. Who wants to spend weeks in a nursing home? Travel across town for routine visits? And obviously, no one wants to be readmitted for a complication. There are ways to cut costs in a bundle that are driven by improving patients’ experience and outcomes. That’s where we should focus. When tools are implemented to create a ‘medical home,’ the continuity of care increases, with fewer gaps in treatment through patient pre-op and rehab. When patients have the tools to take charge of their rehab, they leave skilled nursing facilities more quickly, if they go to them at all, and there is a higher likelihood they will remain on the same page as their physical therapist, making recovery time quicker.
6. Physician benefits. The bundled payment model will offer physicians a chance to make healthcare better, faster and cheaper. Of course, the program is far from perfect. Retrospective annual payment is going to be a bear. Medicare’s decision to put hospitals in charge may prove to be a major missed opportunity. For years, physicians have believed that if only a creaky, bureaucratic payment system got out of the way, they could deliver much better care and a better experience for less cost to the system. CCJR gives joint surgeons and their team a chance to prove it.
Fear should not guide the implementation of this value-based approach to healthcare. Regardless of the operational headaches and uncertainty surrounding CCJR, let’s commit to investing in integrated, coordinated, next-generation joint care that will surely prove to show better outcomes and lowered costs.
If you are a hospital, get moving. If you’re another player (doctor, home health, PT clinic) – get to the table now. Be part of creating the new future, or watch while it’s dictated to you.
by Reflexion Health
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