Becker's Hospital Review

63 Executive Briefing: Preparing for Success under the Comprehensive Care for Joint Replacement Model — Before, During and After Surgery H HS declared lofty goals in January when it announced a his- toric overhaul to shift reimbursements from a fee-for-service to a value-based care model. By the end of 2016, HHS aims to tie 30 percent of traditional fee-for-service Medicare payments to quality or value through alter- native payment models, such as accountable care organizations or bundled payment arrangements. By 2018, this percentage will rise to 50 percent. CMS showed it is serious about holding providers and hos- pitals more accountable for the quality and cost of care when it announced the Comprehensive Care for Joint Replacement Model in July, effective Jan. 1, 2016. CMS said the model will test bundled payment and quality measurement for an episode of care associat- ed with hip and knee replacements, and is designed to incentivize hospitals, physicians and post-acute care providers to work togeth- er to improve quality and coordination from the initial hospitaliza- tion through recovery. About the CCJR Model The agency would implement the proposed model in 75 geographic areas, defined by metropolitan statistical areas — coun- ties associated with a core urban area and a population of at least 50,000. The CCJR model has immediately higher stakes than past bundled payment models, which were voluntary, because hospitals in the 75 areas would be required to participate. "There is a movement nationally toward value-based payment," says Jeff Peters, president of Chicago-based Surgical Directions. "The Comprehensive Care for Joint Replacement Model is a very loud and clear message that this is how CMS is looking to tie 50 percent of reimbursement to value. It's a test case for hospitals." Under the CCJR model, participating hospitals would be held financially accountable for the quality and cost of an episode of care for hip and knee replacements, also called lower extremity joint replacements. The episode would include the 90-day period following discharge. All providers and suppliers would be paid under Medicare's usual payment system rules and procedures for episode services throughout the year. At the end of the performance year, each hospital's actual spending for the episode would be retroactively compared to Medicare's episode price for the responsible hospital, which is based on a blend of hospital- and region-specific costs. De- pending on the hospital's quality and spending, the hospital could receive additional reimbursement from Medicare, or it could be required to repay Medicare for a portion of the episode spending. According to Mr. Peters, joint replacement surgery is a good procedure to test bundled payments on because of its high fre- quency, relative standard process and variable cost. Indeed, hip and knee replacements are two of the most com- mon surgeries among Medicare beneficiaries. According to the latest CMS data, in 2013, there were more than 400,000 inpatient primary procedures for Medicare beneficiaries, incurring more than $7 billion in hospitalization costs alone. Outcomes and costs for these surgeries are vastly different across providers. Rates of complications, such as infections and implant failures post-surgery, could be up to three-times higher at some facilities than others, and the average cost to Medicare for surgery, hospitalization and recovery can range from $16,500 to $33,000 across geographic areas. Additionally, complications can result in hospital readmissions, extended rehabilitative care and pain, which contribute to negative patient experiences and unfavor- able HCAHPS scores. How can hospitals prepare to succeed under the CCJR Model? The program includes three quality measures: 30-day read- mission rate, risk-standardized complication rate and the patient experience. Since payment to participating hospitals is retroac- tively adjusted, hospital executives and clinical leaders must take the necessary steps to optimize costs, reduce complications and readmissions and ensure a positive patient experience, according to Mr. Peters. "The fact that this program is not voluntary makes it more chal- lenging for hospitals," says Mr. Peters. "Before you had the ability to prepare and get ready on your time. Now CMS is saying, 'This is what we're going to do.'" Mr. Peters suggests the following strategies to develop im- proved clinical management pathways. Develop a surgical home and a governance structure to bring the whole care team together The first step to prepare for the CCJR model is to evaluate and restructure the governance model to ensure it will bring together the surgeons, anesthesia, nurses and case coordinators to develop a coordinated model to care for CCJR patients. The care model should extend from the point of scheduling through pre-surgical optimization, surgery, hospital recovery and the 30-day discharge period. The team ensures there is organizational buy-in for best practic- es, standardization of clinical pathways, workflows and order sets. A common organizational model for this is a surgical home, which is responsible for the continuum of a patient's care and ensures cost, quality and patient satisfaction metrics are achieved. Use information dashboards to encourage improvement Surgeons may vary greatly in their expenditure and clinical outcomes. However, it is hard to communicate the urgent need for surgeons to change without providing them and other OR staff with concrete information regarding their personal performance, according to Mr. Peters. "The only way to change behavior is to show individuals their performance levels," says Mr. Peters. "To address this, we suggest developing dashboards so surgeons can see how their perfor- mance compares to the national benchmark, as well as their peers in the same facility." Cost-per-case dashboard reports that show surgeons exactly how their costs compare with reimbursement and to their peers can have a significant influence on their supply choices and surgery time, the latter of which is highly associated with their rates of deep vein thrombosis, surgical site infections and 30-day readmissions. These quality outcomes will have a direct influence on CMS' retrospective payment adjustment at the end of each performance year under the CCJR model, so it is in hospitals' best interest to work with individual surgeons and OR teams to take the necessary steps to prevent surgical and post-op complications, and keep surgical costs as low as possible. These dashboards can also be used to educate nurses and oth- er clinical staff about the cost of common supplies, which reinforces the focus on reducing waste. Expand and enhance pre-admission testing Pre-admission testing is one of the most impactful factors that will contribute to hospitals' success under the CCJR model, accord- ing to Mr. Peters. Sponsored by: Preparing for Success under the Comprehensive Care

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