Improving Patient Outcomes & Costs With CMS CJR Bundled Payments

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As the Baby Boomer generation ages, demand for joint replacements is surging.

As the Baby Boomer generation ages, demand for joint replacements is surging. Today, more than one million knee and hip replacement procedures are performed each year in the U.S. – with a huge spike projected for the road ahead. The American Academy of Orthopedic Surgeons predicts an increase of 673 percent in knee replacements and 174 percent in hip replacements by 2030.

“Joint replacement procedures are one of Medicare’s largest expenditures,” says Robin Hill, vice president of clinical solutions at Vivify Health, a fast-growing international digital health company. “This surgery often contributes to adverse events that can lead to costly hospital readmissions. Clearly, incentives are many to keep patients healthy post-op so they can avoid a return trip to the hospital.”

Spurring efficiencies through a new federal program

To support optimum care for patients undergoing hip and knee replacement, the Centers for Medicare & Medicaid Services (CMS) created the Comprehensive Care for Joint Replacement (CJR) bundled payment model. A mandatory program, the model was launched April 1, 2016, and is being tested for five years at 789 hospitals in 67 markets nationwide.

“The goal of CJR is to help reduce the cost variation in these surgeries, which can range in price from $16,500 to $33,000,” Hill says. “Through CJR, CMS hopes to save more than $150 million over five years – while improving care quality and enhancing the patient experience.”

Moving toward a broader plan

Although CJR is built on the experiences of previous CMS bundled programs, such as the Medicare Acute Care Episode and Bundled Payments for Care Improvement Initiative, it’s the first time that CMS has implemented a bundled payment model in which providers in designated markets are required to participate. “These bundles are part of CMS’s broader plan to move 50 percent of all care it pays for away from fee for service and toward alternative payment models by 2018,” Hill says.

Putting the onus on hospitals

Through CJR, the hospital in which the procedure is performed is accountable for costs and quality up to 90 days after patient discharge. If participating hospitals meet the target price, they will receive an additional payment; if they exceed the target, they will owe Medicare at the end of the year. Hill highlights a key factor for providers in succeeding under CJR: adopting care coordination models that extend care beyond the hospital, including using remote care management (RCM) technology and analytics.

“Joint replacement patients typically follow a rehabilitation program after surgery to speed their recovery,” Hill says. “But ‘prehabilitation’ weeks before surgery, including preoperative physical therapy, can also help them regain function even faster – and also reduce postoperative care costs. The most effective RCM solution includes educational videos that teach patients rehab exercises for use before and after their hospital stay.”

Reaping the benefits of RCM solutions

Bundled payment programs like CJR are prompting providers and payers to collaborate in finding improvement opportunities. According to Hill, RCM technology can help:

  • Enhance continuity of care. The clinical care team has a new avenue for keeping “daily tabs” on patients who have undergone joint replacement procedures, enabling the team to be proactive in monitoring patient biometrics and symptoms. Virtual visits open the door to face-to-face patient interviews and can connect other team players – from social workers and dieticians to patient family members – for a “case conference” with the patient.
  • Control costs. Patients are kept healthy in their homes while costly hospital readmissions are averted. RCM can also decrease in-person visits from home health nurses and reduce the average length of time patients need home health services.
  • Keep patients engaged. At every point in their recovery, patients are encouraged to comply with care plans that achieve the best results from their procedure. Through health information provided by text and video, they are educated on how to control pain, continue their exercises, and manage their recovery. “Patients really appreciate that their care providers are still connected to them after their surgical intervention,” Hill says. “They feel it’s like having a nurse in the home, watching out for them all the time. And family members are secure in knowing their loved one is being cared for remotely each day.”

Getting a head start

Although the CJR 90-day timeframe begins the first day of hospitalization, the optimum course is engaging patients before their surgical intervention, Hill notes. “We recommend that patients be brought into an RCM program one or two weeks before surgery to learn about their procedure and what to expect when they get home. Patients who are educated before their surgical intervention have been found to have better outcomes than those who are not.” She points out that pre-surgery engagement also provides a solid baseline of biometric data, enabling a holistic view of the patient throughout the episode of care.

Riding the wave

Bundled payments are the wave of the future for healthcare. Providers who invest in RCM technology can ride the wave with confidence – increasing their opportunities for success in the new world of pay for value, data-driven health decisions, and team-based, patient-centered care.

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Vivify Health is transforming healthcare with the market’s most comprehensive patient-centered connected care platform, spanning from remote monitoring of high-risk patients and patient activation to population and employee health. Vivify’s platform is the digital pathway to collaborative care on demand — with a focus on ease of use for employees, members, patients and providers.

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