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How Hospitals Succeed Under CCJR: Engage Physicians, Reduce Clinical Variation

On April 1, mandatory bundled payments arrived in orthopedics for lower-extremity joint replacement (LEJR). The Comprehensive Care for Joint Replacement (CCJR) bundled payment program is the first of its kind but there is every indication that CMS will use similar compulsory models in other clinical areas very soon. Understanding and adapting to CCJR will prepare you for these future changes to come. The question, then, is what is the best way to respond?

The CCJR bundle mandates that approximately 800 hospitals across the country assume financial risk for the cost and quality of a complete, 90-day episode of care. The episodes start on the first day of admission and extend through post-acute care for hip and knee LEJRs (MS-DRGs 469-470).

In other words – hospitals are now the payer. They are on the hook not only for the inpatient costs of care but also physician reimbursement and post-acute facility care in skilled nursing facilities, long-term care hospitals, rehabilitation centers and home health within that 90-day period. If hospitals can keep total costs under the target bundle reimbursement they ‘win,’ earning dollars for the difference; they can also add to the win and receive a bonus by earning quality-based performance payments. However, if costs exceed target bundle prices, these hospitals ‘lose’ and must pay CMS back the difference. With so many factors impacting success in CCJR, what are hospitals to do? The answer: engage physicians now and elevate the care they provide to this patient population.

The driving rationale behind CCJR and forthcoming bundled payment models is enhancing the VALUE in healthcare, i.e. providing the highest quality care at the lowest possible price. LEJRs are one of the most common and expensive surgeries incurred by Medicare beneficiaries and the variation in care and outcomes is well documented. For some hospitals, over half of LEJR costs are actually incurred after the patient leaves the hospital, in the post-acute setting. CCJR was designed to incentivize hospitals to work closely with their physicians to reduce the variation in how LEJRs are performed and improve post-procedure care and outcomes. In the LEJR care path, physicians have responsibility for developing best practices based on the evidence base, coordinating and managing several aspects of patient care during surgery and recovery, and ensuring their patients are discharged to an appropriate level of post-acute care.

Physician adherence to best practice standards greatly impacts post-surgical complications and LEJR bundled costs. According to the American Joint Replacement Registry, approximately 70% of LEJR surgical revisions occur within 3 months of the initial surgery, with infection and inflammation being the most common causes of readmission. There is readily-available guidance from the National Surgical Infection Prevention program (2004), Surgical Care Improvement Project (2006) and American Association of Hip and Knee Surgeons (2013) on pre-operative, prophylactic antibiotic infusion that can prevent these infections from occurring. Adherence to evidence-based medicine, however, is poor and the best guidance and protocols have minimal impact if they are not put into practice.

Thus, hospitals must engage their physicians and facilitate alignment around evidence-based pathways to make it under CCJR.  QURE’s President, John Peabody, MD, PhD, in the webinar “Demonstrating Who You Are in CCJR: Data Describes the Problem, Providers Deliver the Solution” (accessible on the QURE website here: CCJR Webinar Link) outlined how to engage orthopedic surgeons in CCJR. QURE recommends an approach that ‘Elevates the Quality of Practice Standardization’ by:

  • Measuring Clinical Practice through use of an easily accessible measurement tool, such as Clinical Performance and Value (CPV®) vignettes, to capture and analyze clinician behavior and practice from intake through post-acute treatment.
    • Baseline measurements, which few institutions do in enough meaningful detail, enable targeted efforts to reduce specific areas of unnecessary variation that impact cost and quality the most.
  • Instilling Accountability by serially assessing individual and group-level performance and improvement on targeting areas of variation.
    • Provide transparent performance scores and incentivize with CME credits.        
  • Facilitating Physician Behavior Change with customized feedback, education on improvement opportunities, and performance comparisons to their actual peers.
    • Group level discussions focused on care variation are among the most efficient ways to standardize practice.

Practice change doesn’t happen overnight. Hospitals will have to begin to lay the foundation for stronger provider engagement and practice changes in orthopedics to avoid CCJR penalties that will begin in one year. Additionally, the best hospitals will heed CJR as a clarion call to consider the changes required to engage physicians in the next targets for mandatory bundled payment (e.g. pneumonia, cardiology). Real cost-savings are only possible when physicians, the key providers of care, shift their practice towards evidence-based standards. In this scenario, hospitals, physicians AND patients win.