by Gloria Kupferman, Vice President, DataGen Group
In November 2015, the Centers for Medicare and Medicaid Services (CMS) issued its Comprehensive Care for Joint Replacement (CJR) payment model, a pilot bundled payment program for the most common inpatient surgeries for Medicare beneficiaries—hip and knee replacements, known as lower extremity joint replacements (LEJRs). CJR will be mandatory for hospitals in 67 Metropolitan Statistical Areas (MSAs). The CJR model will be mandatory for about 800 hospitals.
On November 16, 2015 the Centers for Medicare and Medicaid Services (CMS) released its final rule for the Medicare Comprehensive Care for Joint Replacement (CJR) model. The program will be effective for discharges occurring on or after April 1, 2016, in the 67 designated Metropolitan Statistical Areas (MSAs), unless otherwise noted.
After several months of negotiations you've reached agreement with a contract physician group to provide hospitalist services in your hospital. This group has particular expertise in helping patients with multiple comorbidities and focuses on making sure that those patients get into the proper post-acute setting, which you hope will improve your performance in the Medicare Bundled Payment for Care Improvement (BPCI) CHF and COPD episodes in which you’re participating.
At the National Bundled Payment Summit in Washington DC last June, we presented a session on risk and opportunity in bundled payments. Jon Pearce from Singletrack Analytics gave an overview of risk and opportunity in bundled payments, while Jessica Walradt from the Association of American Medical Colleges and Lily Pazand from NYU Langone Medical Center discussed successes and challenges in their related organizations.
Yesterday CMS issued a proposed rule for the Comprehensive Care for Joint Replacement (CCJR) a proposal to require all episodes of Major Joint Replacement in 75 MSAs to be paid on a "bundled" basis. This is a significant step from the voluntary Bundled Payment for Care Improvement program in that it requires virtually all hospitals (but not physicians or other providers) to be financially responsible for all of the care of these patients for 90 days after discharge. Hospitals in 75 Metropolitan Statistical Areas (MSAs) would be affected.
In recent conversations, articles and seminars we’ve heard wary potential BPCI Model 2 participants propose to select a 30-day episode length as a “safer” alternative to the longer 90-day episode. In some cases the shorter episode length does provide some risk mitigation against uncontrollable high costs such as readmissions. However, that safety comes at a price that may not be warranted. This is because of these two factors:
Jonathan Pearce, CPA, FHFMA and Coleen Kivlahan, MD, MSPH
The Medicare Bundled Payment for Care Improvement (BPCI) program allows participants to assume financial risk for all Medicare services occurring within 30 to 90 day period after hospital discharge. Model 2 participants give up 2% of the episode target amount as a discount to CMS in 90-day episodes, but are allowed to retain any savings from Medicare cost reductions below the target amounts.
As the deadline for submission of April 2015 applications for the Bundled Payment for Care Improvement (BPCI) initiative looms, many applicants are trying to figure out the best approach to selecting risk tracks for various episodes. Some participants are looking for "algorithms" that can assist them in selecting the most appropriate risk track, while others are noting that risk track can be changed throughout the participation period, and may wish to switch risk tracks based on their performance during a previous quarter.