Sixty-seven metropolitan areas in the United States became subject to bundled payment rules for Comprehensive Care for Joint Replacement (CJR) on April 1, 2016. Although the concept seems simple and straightforward – all hospitals involved are held financially accountable for quality of care, utilization and outcomes over a 90-day episode for major joint replacements – how it impacts clinical and operational processes is something with which many providers wrestle.
In practice, the regulations will test how well aligned physicians are with acute care providers. The Centers for Medicare & Medicaid Services (CMS) believes that bundled payments will improve coordination of care for patients and help achieve their goals for better health, better health care and lower costs.
Critical to success for impacted hospitals is collaboration with orthopedic surgeons. It is estimated that physicians directly and indirectly control 80 percent of what is spent on health care, so gaining their buy-in and collaborating on a 90-day care plan will be fundamental for success. CJR will include waivers to allow for economic alignment among providers to further interest in cost and quality improvement.
With the new mandatory program now in effect, it is important to make sure there is alignment with physicians as well as an alignment of internal processes. Below are seven key focus areas that will enable you to identify opportunities, improve outcomes, facilitate care coordination, lower costs and improve reimbursements.
- Review your hospital’s 90-day Medicare spend, utilization and quality metrics to understand how you stack up compared to other hospitals in your region
- Develop robust care coordination services that begin prior to surgery and extend through hospitalization and a 90-day post-acute period
- Create collaboration agreements with physicians who are instrumental in cost and quality outcomes
- Evaluate quality, utilization and costs for post-acute care providers, i.e. skilled nursing facilities, home health care, inpatient rehabilitation, to create a narrow network of high quality, efficient providers
- Review and improve discharge planning and care navigation strategies
- Consider investing in virtual health technologies where appropriate to improve coordination with patients, family members, caregivers and others within patient support networks
- Improve utilization of electronic medical records and interfaces with specialty-focused applications to track outcomes and patient compliance
CJR is expected to be the first of many mandatory bundled payment initiatives to come. Use the strategies above to be ready to succeed with CJR and other initiatives as they are implemented.
About the author. Jim Reilly’s career includes more than 20 years’ experience in health care consulting with health systems and physician practices nationwide. His experience includes hospital/physician alignment, bundled payments, strategic planning, new service development, and market growth planning and implementation. He has led more than 300 projects during his consulting career and is a national speaker with organizations such as the American College of Healthcare Executives and the American Medical Group Association on hospital/physician alignment models.
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