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16 Executive Briefing 7 Key Areas to Address Under the Comprehensive Care for Joint Replacement Model I n the past, healthcare providers' pay was primarily driven by the volume of patients and services rendered, with weaker correlation to outcomes. However, the healthcare industry — led by initiatives enforced by CMS — has embarked on a permanent departure from this approach. Under a value-based system, healthcare organizations are rewarded for care that produces the best possible outcomes for the lowest possible cost. Bundled pay- ments are central to such a system. Under this model, providers are paid a set amount for an entire episode of care, from pre- to post-operative care. They either share in savings or absorb the extra costs associated with complications, extended length of stay or readmissions. The Comprehensive Care for Joint Replace- ment Model, CMS' first mandatory reim- bursement model of its kind, focuses on hip and knee replacement. About 800 hospitals across 67 markets are participating in CJR, which took effect April 1, 2016. During the five-year program, hospitals are still paid according to existing Medicare fee-for-ser- vice rules throughout the year. At the end of each performance year, however, CMS compares a hospital's spending for a care episode to the target episode price. An ep- isode begins from the time a patient is ad- mitted to surgery through 90 days post-dis- charge, including care in skilled nursing facilities. Depending on the participant hospital's quality and spending performance, the hospital may receive an additional pay- ment from Medicare or be required to re- pay Medicare for a portion of the episode spending. In July, CMS proposed new provisions to CJR, which would extend the model to in- clude hip and femur fractures. Under the proposal, the hospital in which a patient is admitted for surgical hip or femur fracture treatment would be accountable for the cost and quality of care during the inpatient stay, as well as for 90 days after discharge. Hospitals would receive a fixed payment for each care episode. Those that deliver care for less than the target price while meeting or exceeding quality standards would keep the savings achieved. Hospitals with costs exceeding the target price would have to repay Medicare. To succeed under CJR, participating hos- pitals must make structural and cultural changes. Many of these changes can be borrowed from institutions that thrive un- der older bundled payment initiatives, such as the 2013 Bundled Payment for Care Im- provement Initiative. Here are seven key areas upon which hospital leaders and cli- nicians must focus. 1. Empower physician leaders to drive change. One critical culture change imper- ative for success under CJR is creating a structure that aligns physicians and hospital administrators, while also providing clinicians with necessary education of the new model. "Allowing physicians and hospitals to align in any bundle situation is critical to the success of the initiative," Richard Iorio, MD, chief of adult reconstruction at the Department of Or- thopaedic Surgery at NYU Langone Medical Center, said during a webinar hosted by Paci- ra Pharmaceuticals. Indeed, the importance of strong leader- ship among surgeons, anesthesiologists and nurses under the CJR model cannot be over- stated. However, clinicians need sufficient education on the changes they are required to make before they will be willing to alter their approach to care delivery, let alone act as leaders of change. Surgeon education is particularly perti- nent. According to Jeff Peters, CEO of Chi- cago-based Surgical Directions, effective surgeon education efforts must include an overview of bundled payments, with atten- tion paid to their effects on reimbursement and a breakdown of what services are in- cluded in the target price. Hospitals should also illuminate how they compare with oth- er hospitals' clinical, financial and patient satisfaction outcomes. In addition to bolstering physician education, it is critical for hospitals to develop strong governance models that include clinical stakeholders. One such example is a Surgical Services Executive Committee, which brings a variety of leaders — senior administrators, medical directors, surgeons, anesthesiolo- gists, nurses and ad hoc members — to the table to refine clinical pathways. "The SSEC brings together all of the disciplines affected by bundled payment so there are representa- tives at the table when decisions are made," Mr. Peters said during a webinar sponsored by Pacira. 2. Develop metrics that quantify opera- tional, financial and patient satisfaction improvement opportunities. Physicians are methodical creatures and their behavior is driven by evidence-based reasoning. To fuel surgeons' intrinsic desire to improve, leaders should share concrete data on individual and hospital performance. "Data, clarity and transparency of data are critical for this whole process," said Dr. Io- rio. "Both financial and quality metrics need to be communicated to the physicians; this reinforces good behavior and penalizes bad behavior." NYU Langone physicians receive quality and financial metrics on a biweekly basis. The data is completely transparent — it is even posted online, according to Dr. Iorio. Physicians see their quality and financial performance compared with their peers. As a result, surgeons' inherent sense of com- petition drives them to improve — whether that is choosing more cost-sensitive im- plants, reducing OR time or reducing read- missions. Hospitals have also found surgeon score- cards drive change, according to Mr. Peters. Surgeon scorecards record data on various metrics — including clinical, financial and patient satisfaction measures — for each individual physician and compare those results to peers in the hospital as well as regional or national benchmarks. However, Mr. Peters stressed that surgeon scorecards should facilitate a nurturing, educational process, not a punitive one. "You want an ongoing collaborative working relationship with the surgeon," said Mr. Peters. 3. Educate patients on what to expect ahead of surgery. At NYU Langone Medical Center's Hospital for Joint Diseases, clinical care coordinators identify and assess pa- tients who qualify for the BPCI Initiative be- fore they are admitted for surgery, according to Deserie Duran, RN, assistant director in HJD's department of care management and social work. "The BPCI clinical care coordinator calls the Sponsored by: