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CMS report showed CJR model may reduce care episode costs
Under the CJR model, quality of care was also maintained despite concerns related to access to care
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Bundled payments for lower-extremity joint replacement episodes may result in reduced payments under the Comprehensive Care for Joint Replacement model, according to the first annual report published by the CMS.
The report included findings from April 1, 2016, to December 31, 2016, reported by hospitals paid under the Medicare inpatient prospective payment system and located in the 67 metropolitan statistical areas included under the Comprehensive Care for Joint Replacement (CJR) payment model.
Reduced costs in episodes of care
In results in the report, there was a 3.3% decrease in total episode payments for CJR episodes compared with control group episodes. Metropolitan statistical areas with historically high and low episode payments experienced decreases in average total payments for CJR episodes of $1,127 and $577, respectively.
Separate analyses that were performed using data for elective lower extremity joint replacement and lower extremity joint replacement due to fracture showed a reduction in average total payments for both episodes, according to the CMS report.
The report noted there was a relative decrease in inpatient rehabilitation facility (IRF) as the first post-acute care setting used following elective episodes, as well as a relative increase in the home health agency as the first post-acute care setting used. Fracture episodes showed a relative increase in the proportion of patients discharged to a skilled nursing facility (SNF) and a decrease in the proportion of patients discharged to an IRF. Furthermore, there was a statistically significant relative reduction in the average number of days spent in the institutional post-acute care setting for CJR patients with elective or fracture episodes who were discharged to either a SNF or IRF.
“The report found that reductions in total episode payments were driven by reductions in the use of more intensive post-acute care settings and shorter lengths of stay in post-acute care settings, without indications of reduced quality of care,” a CMS spokesperson told Orthopedics Today.
Maintenance of quality care
The CMS spokesperson said quality of care was maintained under the CJR model with no impact on readmission rates, ED visits and mortality. Although incentives to admit healthier patients or avoid higher risk patients to reduce average total episode payments have raised concerns among participating hospitals regarding to how access to care for sicker or more resource intensive patients would be impacted, the CMS report showed “no indications that the CJR patient population was healthier in the intervention period than in the baseline, relative to the control group population.”
Ultimately, the report highlighted some common themes identified by participant hospitals that can be used as strategies in reducing episode costs.
“While the response to the CJR model varied across hospitals, hospitals reported that common themes in the strategies they took to reduce episode costs included bolstering patient education, optimizing high-risk patients prior to surgery, engaging surgeons in care redesign efforts, standardizing care pathways and protocols, following-up with patients after discharge and improving coordination with post-acute care providers,” the CMS spokesperson said. – by Casey Tingle
Reference:
CMS Comprehensive Care for Joint Replacement model: Performance year 1 evaluation report. Available at: https://innovation.cms.gov/Files/reports/cjr-firstannrpt.pdf. Accessed Sept. 18, 2018.
For more information:
CMS can be reached at 7500 Security Boulevard, Baltimore, MD 21244; email: william.polglase@cms.hhs.gov.
Perspective
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A. Seth Greenwald, DPhil (Oxon)
Measuring the quality of patient care relies on the realization that patient-reported outcome studies (PROS) remain the same or improve. Concomitantly, costs for each episode of patient care ideally decrease. This ratio is the essence of value-based care envisioned under the CJR program. The 67 urban districts sampled over a 9-month period reported dramatic cost savings in post-acute care, which at one point amounted to more than 40% of the bundle. As a follow-on to this report, serious attention will be paid to the increasing number of ASCs to determine the significance of their PROS and resulting cost-savings. Peer-reviewed literature documenting ASC performance will help to define a CJR reimbursement model for lower-extremity reconstruction. Further, these data will force a re-examination of the comorbidities that justify inpatient care. Evolving patient-worn telemetry systems where patient vitals are monitored with direct connection to the surgeon’s office will further decrease both time and cost. Patient education becomes extremely important in this context. The ongoing evaluation by CMS of the CJR program that embraces the above is manifest.
Perspective
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Amy Finkelstein, PhD
The findings in the report are generally consistent with what we found in our JAMA paper published this month: results from this randomized evaluation indicate that, in its first year, Medicare bundled payments for lower-extremity joint replacement reduced health care use with no apparent harm or benefit to health care quality; there were also no effects on patient volume or case mix. Specifically, bundled payments reduced discharges to institutional post-acute care (defined as discharges to IRFs, SNFs and long-term care hospitals) and episode spending for institutional post-acute care. However, there were no net savings to Medicare, where net savings is defined as Medicare spending inclusive of bonus payments to hospitals that reduced their health care spending and met quality targets.
Whether the bundled payment model can achieve net savings is currently an open question, which results from the first year alone cannot answer. It will be important and interesting to see what happens in the next 4 years of this 5-year program. Hospitals may take a while for their behavior to change. In addition, the financial incentives will increase substantially over the next few years.
It is laudable that CMS undertook a rigorous, nationwide, mandatory randomized evaluation of this important alternative payment model. It is therefore unfortunate that 2 years into the 5-year program CMS scaled back the number of markets in which CJR is mandatory. While we will still be able to rigorously evaluate bundled payments in the markets where they remain mandatory, this change will create challenges for fully evaluating the impact of bundled payments using the rigorous methods of randomized evaluation.
Reference:
Finkelstein A, et al. JAMA. 2018;doi:10.1001/jama.2018.12346.
Massachusetts Institute of Technology
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