Medicare Comprehensive Care for Joint Replacement Payment Model Aims to Increase Hospital Accountability for Quality Care

Get the Skills to Succeed in Value-Based Care

Physicians and administrators are feeling uncertainty about the multitude of changes to the health care delivery system. The Pennsylvania Medical Society’s (PAMED’s) CME series of six online, on-demand courses and live workshops in Harrisburg on Aug. 7 and Oct. 9 is designed to help address that uncertainty. It is possible not just to survive but also to thrive in value-based delivery, and PAMED can help you acquire the skills you need.

Learn more about this education and register.

The Centers for Medicare and Medicaid Services (CMS) has proposed a major Medicare initiative for hip and knee replacements. The Comprehensive Care for Joint Replacement payment model proposes to hold hospitals accountable for the quality they deliver to Medicare fee-for-service beneficiaries for hip and knee replacements from surgery through recovery.

Through the proposed five-year payment model, health care providers in 75 geographic areas, including the Metropolitan Statistical Areas Harrisburg/Carlisle, Pittsburgh, and Reading, Pa., would continue to be paid under existing Medicare payment systems. However, the hospital where the hip or knee replacement takes place would be held accountable for the quality and costs of care for the entire episode of care — from the time of the surgery through 90 days after discharge. 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.

As a result, hospitals would have an incentive to work with physicians, home health agencies, and nursing facilities to make sure beneficiaries get the coordinated care they need, with the goal of avoiding hospitalizations and complications. According to CMS, these bundled payments for joint replacement surgeries would build upon successful demonstration programs already underway in Medicare.

Comments on the proposal will be accepted until Sept. 8, 2015.

If you are looking to comment on the proposal you may first want to review Harold Miller’s insight on the proposal. Mr. Miller is executive director of the Pittsburgh-based Center for Healthcare Quality & Payment Reform. He has indicated that the model “turns out to be primarily a plan to penalize hospitals when patients receive higher-than-average amounts of post-acute care services after knee or hip surgery.” He goes on to state that “the plan is implemented in a way that could lead to many very problematic results, including:

  • Encouraging further consolidation in the health care industry, fewer choices for consumers, and higher prices for private purchasers; and
  • Discouraging truly innovative approaches to managing hip and knee problems and encouraging unnecessary surgeries.”

To better understand how to contract for bundled payments, CMS working with The MITRE Corporation developed a guide — Contracting for Bundled Payment —to help providers and organizations partner to provide services through the bundled payment environment.

Additionally, The Physicians Foundation in cooperation with the North Carolina Medical Society has developed the publication The Bundled Payment Guide for Physicians. The purpose of the guide is to acquaint physicians with this emerging health care reform model and to provide non-technical guidance specifically for physicians.

“We’re constantly talking about value-based purchasing, value-based measures, and educating the medical staff and the board, so this [education] has been a very good exercise in learning how to use some of the value-based measures and how they are going to apply as we go forward. It was a very useful conversation,” said Carmine Cerra, MD, an attendee at the June 12 workshop. Dr. Cerra, a physician at Pocono Medical Center in East Stroudsburg, is on the hospital board and chairs the performance improvement committee.

“We’ll get there, but I think we’ll get there more quickly and with fewer speed bumps if doctors are as engaged as this education can enable them to be,” said PAMED member Jaan Sidorov, MD, who also attended the first live workshop in June. “The biggest takeaway for me was change is really beginning to happen at the speed of light,” he said. “I think a lot of it [the volume to value movement] is going to happen at the ground level, so the workshop really enabled me to think more intelligently about what I can do locally, with my hospital, with my elected representatives, to advocate for the right decision making.”