Inpatient Facility Coding & Compliance Alert

Hospitals to get incentive/ penalty as per the quality outcomes.

Your joint replacement treatment protocol is in for a new boost in January 2016. More than 800 acute care hospitals in select areas of the U.S. are slated to undergo a new payment initiative for hip and knee replacements.

Background: The initiative, known as the Comprehensive Care for Joint Replacement Payment Model (CCRJ), is a bundled care model that CMS proposed last July with a test period between Jan. 1, 2016, through Dec. 31, 2020. The model would hold participating hospitals accountable for the quality of care they deliver to Medicare fee-for-service beneficiaries receiving hip and knee replacements for the entire episode of care. This means hospitals would be responsible for outcomes from admission through 90 days post-discharge, including all related care, both Medicare Part A and Part B.

Caveat: Unlike a typical CMS demonstration project, participation is mandatory for the selected facilities.

“The real issue, from the hospital’s perspective, is that hospitals are being held accountable for care that they do not (or may not) control,” explains Duane C. Abbey, PhD, president of Abbey and Abbey Consultants Inc., in Ames, IA. “This is particularly true for post-operative care that may be provided by someone else other than the hospital. There is a very general maxim that one, individually or organizationally, should never be held accountable for that which they do not control.”

Provide Good Care, Get Good Pay (and Vice Versa)

All providers would continue to receive payments under existing Medicare payment systems. However, depending on the hospital’s quality and cost performance during the episode, the hospital may receive an additional payment or be required to repay Medicare for a portion of the episode costs. To determine this, each year CMS would set Medicare episode prices for each participant hospital. At the end of each model performance year, CMS would compare actual spending for the episode (including Medicare Parts A and B) to the Medicare estimate.

Know the Rationale Behind the Initiative

Why did CMS bring in a new model over the existing one?

“The Medicare program really wants to move toward an overall episode of care for payment purposes,” tells Abbey. Moreover, Medicare also realized the following:

Huge variations in cost: “The quality and cost of care for these hip and knee replacement surgeries still vary greatly among care providers,” CMS stated in a press release, citing that the rate of complications after surgery can be more than three times higher at some facilities than others and can cost anywhere from $16,500 to $33,000.

Incentives for better care: Hospitals would have an incentive to work with physicians, home health agencies, nursing facilities, and other post-acute care providers to make sure beneficiaries get the coordinated care they need, with the goal of reducing avoidable rehospitalizations and complications, CMS said. “The issue at hand is that multiple providers, who are often not part of the same organization, will be involved in the episode of care. Thus, maintaining and measuring quality for the care during the episode of care becomes problematic. To some extent this is why health care is moving more toward IDSs (Integrated Delivery Systems) and/or ACOs (Accountable Care Organizations). This means that hospitals will have to develop and devote additional resources in order to meet any performance standards.”

Consider These Suggestions From APTA

While the CCRJ payment model would not change how rehabilitation providers are paid, therapists may still feel an impact. The proposed CCJR model closely resembles the BPCI (Bundled Payments for Care Initiatives) program that was greeted with mixed reviews from hospital and post-acute providers who explored the option previously. In its comments to CMS, the American Physical Therapy Association (APTA) supported the agency’s initiatives to improve quality and access to patient care. However, APTA suggested:

• Delaying implementation for at least a year
• Making participation voluntary
• Ensuring patient choice and access to care.
• APTA also suggested allowing waivers for telehealth, outpatient therapy limits, and other care variations that reflect a patient-centered, rather than regulation-based, approach to care.

The road ahead: “On top of this general challenge (i.e., being held accountable for something not controlled) there is the issue of just how CMS will implement this whole process,” clarifies Abbey. “To some extent, hospitals that are required to participate may be working with moving targets when it comes to performance measures.”

What’s more, the discharge planner at your hospital will also need enough knowledge to assure that a qualified and appropriate outpatient rehabilitation practitioner (one familiar with joint replacement rehab) is available for your patient post-discharge from the hospital. This may be beyond the knowledge and scope currently but in future, more emphasis on care coordination would be needed. Improving and expanding discharge planning to comprehensive care coordination over time would be a positive goal to achieve under this model.