Sailing Through CJR to Maximum Financial Health

As we finish out this series on CJR, it is important to recall that with the launch of the Comprehensive Care for Joint Replacement (CJR) reimbursement model, Centers for Medicare & Medicaid Services (CMS) refocuses patient care for lower extremity joint replacements (LEJR). Through bundled payments that align the incentives of providers along the entirety of the care continuum, health systems are becoming increasingly accountable for the cost and quality of an episode of care. Yet even in these uncharted waters, health systems can continue to sail smoothly to maximum financial health. Specifically, there are a few tips that we recommend your health system employ along this voyage.

For example, to maintain the focus on the highest quality of care, your health system will benefit from focusing on elements that align with the parameters of the CJR model. These elements include reducing readmissions, standardizing high quality of care through integration, and focusing on patient experience.

QualityofCare

In reducing readmissions, your health system will benefit from working closely with all post-acute care (PAC) providers in the patients’ care continuum. By forging an effective relationship that aligns incentives, your health system will financially benefit from the target pricing in the CJR model, specifically as unplanned readmissions have been identified as a key measure of outcome quality in the CJR model. fin-risk

In standardizing high quality of care through integration, your health system will benefit when LEJR patients choose to stay within your network. Integration and CMS “gainsharing” agreements keep revenues within the system, and with the system’s preferred providers, and allows for reduced readmissions and length-of-stay(LOS), maximizing cost efficiency for your patients. In focusing on patient experience, your patients’ satisfaction will be directly linked to improved LEJR outcomes through the use of the Hospital Consumer Assessment of Healthcare Providers and Systems survey. Now more than ever, patients will expect a more patient-centered approach to care and coordination across different care settings.

Furthermore, your health system will be able to stay the course while navigating the CJR model by ensuring that patients have full choice in PAC provider options. At the end of the day it is the patients’ choice as to where they will transition to and it is important for your patients to choose the right PAC provider. Also, there is variability in care and those outside of your network may not necessarily meet your high standards. To ensure that patients understand the importance of selecting the proper PAC provider, it is important that they be educated on the advantages that your integrated network offers. In doing so, your health system needs a proper tool that is flexible enough to guide patients during this critical bedside decision-making moment.

However, to continue to provide the highest quality of care while maximizing financial health, your health system will not have to sail these changing winds alone. With the right tool, your health system can navigate the CJR waters confidently. A transparent tool that aligns the financial incentives of PAC providers with those of your health system will ensure coordination in the quality of patient care across the care continuum. By utilizing CMS data to allow patients to make an informed care transition, the right tool will increase revenues through integration, or agreements with providers outside of your network, as well as decrease costs through reduced readmissions and LOS. In this sense, while navigating the uncharted waters of the CJR model will not be simple, be confident that your health system can continue to provider the highest quality of LEJR care while sailing home to maximum financial health.

About Janus Choice

Janus Choice can help your health system navigate through this journey by providing you with the digital tool you need to succeed. Janus Choice facilitates informed healthcare transitions between different care settings. With a proven history, we offer an interactive, mobile, and easy-to-use platform for matching patients with the best post-acute care providers. Janus Choice increases top-line revenue for health systems and increases integration of patients that require post-acute care. Request a demo today at [email protected].


1. CMS. Comprehensive Care for Joint Replacement (CJR) Model. https://innovation.cms.gov/Files/fact-sheet/cjr-fs-finalrule.pdf. November 2015.

2. Federal Register. https://www.federalregister.gov/articles/2015/11/24/2015-29438/medicare-program-comprehensive-care-for-joint-replacement-payment-model-for-acute-care-hospitals. November 2015.

3. Medicare Program; Comprehensive Care for Joint Replacement Payment Model for Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services

https://www.federalregister.gov/articles/2015/11/24/2015-29438/medicare-program-comprehensive-care-for-joint-replacement-payment-model-for-acute-care-hospitals. November 2015.

4. CMS. Comprehensive Care for Joint Replacement (CJR) Model. https://innovation.cms.gov/Files/fact-sheet/cjr-fs-finalrule.pdf. November 2015.

5. Ibid.

By |May 23rd, 2016|CJR, LEJR|0 Comments

Navigating Through the CJR Model

As we discussed in part 1 of our series, a new payment model is revolutionizing the way Medicare reimburses providers. To stay afloat in this transition and continue to provide the highest quality of patient care while maximizing financial health, health systems will not only need to understand the new payment model but also grasp ways to navigate through it smoothly.

Previously, Medicare made separate payments to each provider for the patient. Providers include hospitals, post-acute care providers, physicians, and nurses, and each service and Medicare payments followed the quantity of procedures and tests delivered to patients. By offering payments for individual procedures, this Medicare payment model overlooked the benefits of the broad aspects of care.

However with a new payment model, healthcare is beginning to account for the big picture of care. On April 1, 2016, Medicare launched the Comprehensive Care for Joint Replacement (CJR) reimbursement model for the most commonly Medicare-reimbursed inpatient surgery: hip and knee replacements (i.e., lower extremity joint replacements or LEJR). For these procedures, the average total Medicare expenditure for the episode of care, including surgery, hospitalization, and recovery, is highly variable, ranging from $16,500 to $33,000 across all geographic areas.

The CJR model refocuses patient care by attempting to reduce this variation. Instead of reimbursing each provider for individual procedures, this payment model utilizes bundled payments that align the incentives of the providers with those of the hospital. By incentivizing the coordination of care, the new payment model supports coordination not only across different settings but also across different providers, rewarding providers who work together to deliver care to patients.

In this payment model, each episode of care is evaluated in terms of the quality of care provided and cost performance. To assess quality of care, two measures (Hospital-Level Risk-Standardized Complication Rate, Hospital Consumer Assessment of Healthcare Providers and Systems survey), make up a composite quality score. To assess cost performance, the dollar amount spent across the episode of care is compared to an established price target for that specific episode. Target prices for specific episodes will be given to participating hospitals at the beginning of the year and these targets prices will reflect whether the episode involves major complications, as well as whether it involves a hip fracture. Target prices will also reflect historical data both from hospital-specific spending and regional spending.

At the end of the year, hospitals that have achieved LEJR spending below the target price and have a sufficient quality score will be eligible for an additional payment from Medicare to make up for the difference between the target price and the actual spending per episode. Hospitals with LEJR episode spending that exceeds the target price will be financially responsible for paying the difference to Medicare. In this way by comparing actual spending per episode to the established Medicare target price, the quality and spending per episode will allow hospitals to either receive an additional payment from Medicare or be required to repay Medicare for the portion that exceeds the established target price.

With this new payment system, the CJR model holds the hospital financially responsible for an episode of care, a system that not only incentives the coordination of care across settings, but also refocuses care on delivering the highest quality of patient care. Now more than ever, health systems will need to take on new responsibilities to align care delivery with new incentives and sail smoothly through these uncharted waters.

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About Janus Choice

Janus Choice facilitates informed healthcare transitions between different care settings. With a proven history, we offer an interactive, mobile, and easy-to-use platform for matching patients with the best post-acute care providers. Janus Choice increases top-line revenue for health systems and increases integration of patients that require post-acute care. Request a demo today at [email protected].


Sources:

1. CMS. Bundled Payments for Care Improvement (BPCI) Initiative: General Information. https://innovation.cms.gov/initiatives/bundled-payments/. April 2016.

2. CMS. Comprehensive Care for Joint Replacement (CJR) Model. https://innovation.cms.gov/Files/fact-sheet/cjr-fs-finalrule.pdf. November 2015.

3. CMS. Bundled Payments for Care Improvement (BPCI) Initiative: General Information. https://innovation.cms.gov/initiatives/bundled-payments/. April 2016.

4. CMS. Comprehensive Care for Joint Replacement (CJR) Model. https://innovation.cms.gov/Files/fact-sheet/cjr-providerfs-finalrule.pdf. November 2015.

5. Ibid.

6. CMS. Comprehensive Care for Joint Replacement Model. https://innovation.cms.gov/initiatives/cjr. March 2016.

By |May 3rd, 2016|CJR, LEJR|0 Comments

The Coming Change …

Did you know?

How the government pays healthcare providers is changing. On the horizon is an increased emphasis on making hospitals and health systems more accountable for patients’ entire continuum of care.

One example … In early 2016, the Centers for Medicare & Medicaid Services (CMS) announced details of a new payment model for hip and knee replacements (i.e., also called lower extremity joint replacements or LEJR) called the Comprehensive Care for Joint Replacement model (CJR). LEJRs are surgical procedures CMS targeted because of their high frequency in the elderly, inpatient stay requirement, and cost (CMS paid out $7+ billion for 400,000 such procedures performed in 2014!).

The proposed reimbursement model is being piloted at 800 hospitals and is designed to hold the facility more accountable for the cost, quality, and outcome of these joint replacements, beginning on the day of the operation and extending through 90 days of rehabilitation. Unlike traditional fee-for-service reimbursements, the hospital will instead receive a pre-determined bundled amount for the entire period of care.

At the end of the year, there will be an eventual reconciliation to actual spending by CMS. And depending upon the findings with respect to quality/outcome of care and the hospital’s actual cost, the hospital could receive additional payments from CMS. Or, it may be asked to pay back a portion of the original reimbursement.

With this shift in accountability, it would seem to behoove hospitals and health systems to work more closely with the follow-up care providers (inpatient rehabilitation facilities and nursing homes, for example). They’ll want to maximize patients’ therapeutic results while minimizing their length of stay.

Because it is the cost of those post-hospital settings which account for the majority of the cost variation for the global care of knee and hip replacements, health systems have a significant financial stake in their patients’ choice of post-hospital facility. Yet, an estimated 60% of health systems are at risk of being penalized based on their current cost performance. And more than half of hospital providers feel unprepared for this global payment model.

How can health systems meet the demands of the new payment model and still maximize financial health?

About Janus Choice

Janus Choice facilitates informed healthcare transitions between different care settings. With a proven history, we offer an interactive, mobile, and easy-to-use platform for matching patients with the best post-acute care providers. Janus Choice increases top-line revenue for health systems and increases integration of patients that require post-acute care. Request a demo today at [email protected]


Sources:

1. CMS. Comprehensive Care for Joint Replacement Model. https://innovation.cms.gov/initiatives/cjr. March 2016.

2. Ibid.

3. Ibid.

4. Ibid.

5. Avalere. Sixty Percent of Hospitals Must Reduce Costs for Joint Replacement Under New Medicare Demo or Face Penalties.

http://avalere.com/expertise/managed-care/insights/sixty-percent-of-hospitals-must-reduce-costs-for-joint-replacement-under-ne. April 2016.

6. Health Leaders Media. Majority of Hospitals Eye Losses in CJR. http://www.healthleadersmedia.com/finance/majority-hospitals-eye-losses-cjr?page=0%2C1#. April 2016.

By |April 19th, 2016|CJR|0 Comments
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