New Developments For Knee Replacement Payment Model

Some communities will be involuntarily forced to test the new bundled payment model coming in April, 2016. This is a delay from the anticipated start date of January, 2016. In this article I will be helping you to interpret “Government-Speak”. Red-lettered text in brackets, are my editorial comments and interpretation. This article has been reprinted from US News and World Report 

Surgeons at Akron General Medical Center are rethinking their whole approach to hip and knee replacement surgery. {The government will eventually force them to if they do not get ahead of the curve now} The transformation underway in Akron will sweep through hospitals in 67 cities {Reduced from an original 75 cities} next year (Originally set to start in January. 2016} and eventually thousands nationwide.

Here is the new list of 67 cities

The stakes are high. Failure to get it right could cost the hospitals millions, as Medicare begins phasing in plans to pay hospitals not for the number of services they provide but for high-quality episodes of care provided at the lowest possible cost. {“Quality care” and “lower costs” are terms inevitably lumped together however this is primarily about cutting costs}

CMS announced Monday {11/16/15} that the most ambitious phase of the new program will begin April 1, 2016, when Medicare will begin putting in place a plan to put each hospital at financial risk for the cost and quality of each joint replacement procedure, including care provided outside the hospital for up to 90 days

Putting hospitals at financial risk for the cost of care is a powerful incentive to get it right. Unnecessary procedures, {How on earth will anyone know if a procedure was unnecessary?} complications, hospital readmissions and extended care provided in costly “post-acute” settings such as rehabilitation centers all may {will} drive up costs and increase the likelihood that hospitals will end the year owing Medicare money. {For the vast majority you can kiss SNF post TKR goodbye} Hospitals that reap savings will be able to reward physicians and other care providers, providing them too with an incentive to boost quality and cut cost {Again this idea that they are going to boost quality and cut costs}

Hip and knee surgery is just the beginning. Goals set by Health and Human Services Secretary Silvia Burwell this year require half of all Medicare payments to be shifted into alternative models like the Comprehensive Care for Joint Replacement (CCJR) program by 2018 {Joints fit into a neat and tidy episode of care but it is doubtful that other disease processes will prove so amenable}, while 90 percent of payments will be tied to the quality of care. {By the way, linking paybacks to quality of care encourages the healthcare system to avoid caring for the sickest individuals or to deny care to those who fall into a high risk category.}

Dr. Patrick Conway, director of the Center for Medicare and Medicaid Innovation, who is in charge of implementing the new approach, says early pilot studies of so-called bundled payment programs have yielded “promising results.”

Large Scale Roll Out

large scale rollout for knee replacement surgery“We want to test this on a larger scale,” Conway said. “We think hospitals, physicians and post-acute providers will be able to partner together and deliver higher quality and more efficient care.” {In other words the less rehab that is provided the more money the doctors will make.}

Getting the parties together to talk is an achievement unto itself, says Kevin Bozic, chairman of surgery at the Dell Medical School of the University of Texas, Austin. “It’s the first time that all the people involved in the care of the patient are all sitting down to decide what makes the most sense.” {It’s also the first time in history that some parts of the healthcare system are being asked to cannibalize other parts of the healthcare system in order for them to profit.}

“Patients think we’re already working together,” Bozic added. “It’s shocking to them that these partnerships don’t already exist.” {This is just absolute hogwash-the good surgeons absolutely know what their rehab pipeline is doing because it reflects on them as a surgeon}

To prepare, hospitals are overhauling every aspect of the care they provide to joint replacement patients, {The problem with this is that we already do a damn good job with minimizing complications and re-admissions. There is really no reason for a wholesale restructuring except to save money} says Dr. Thomas Thompson, Akron’s chairman of orthopedic surgery.

“It’s a huge and complicated undertaking,” Thompson said. “It’s a challenge every institution will face. And the smaller ones will find it difficult to accomplish if they’re totally on their own.”{This is why I predict that the smaller ones will eventually just stop doing the procedure. Fewer hospitals providing the surgery will result in longer wait times unless they increase capacity at the larger institutions-We will have to wait to see if that happens}

Hospitals have no choice but to satisfy Medicare; Medicare is their biggest customer. In 2013, the most recent year available, Medicare covered 400,000 inpatient joint replacement procedures with costs totaling more than $7 billion for hospitalization alone. Virtually all the procedures done that year were fee-for-service, meaning the hospital billed Medicare separately for every service it provided.

If a patient ended up with a hospital-acquired infection, or needed a longer length of stay, the hospital billed Medicare for the additional care. If a patient needed extended care in a rehabilitation center or a skilled nursing facility, Medicare paid for that separately too. Studies indicate that quality and cost vary dramatically at facilities nationwide. {One reason is the regional differences in pricing that exist just like in the housing market- a flat rate would discriminate against places that have higher costs to do business like salaries, taxes etc. The other important point here is that if a hospital has a ton of extra costs that seem to stem from poor care why not just put a cap on extra reimbursement after a certain limit or suspend them from doing Medicare joints altogether until they retrain or otherwise demonstrated that care has improved. There are plenty of other less disruptive options that could have been tried first before overhauling an excellent system}

For instance, Medicare data shows that the rate of complications or implant failures is three times higher at some institutions than others. {I’m not sure if they are controlling for comorbidities or not. If they are not then this is a ridiculous and misleading statement. Additionally implant failure almost never happens in the 90 day window that is being addressed in this new proposed rule} And the average Medicare payment for surgery, hospitalization and recovery ranges from $16,000 to $33,000, depending on where the surgery is performed.

Transform Care?

change-948016_640What makes the change even more significant is that it promises to transform the way care is delivered to every hip or knee replacement patient – not just those 65 and older. {Government Rules and regulations having been the driving force in healthcare for years} Hospitals don’t vary the care they provide based on a patient’s insurance. That means any change put in place to satisfy Medicare will affect every hip or knee replacement patient no matter how old they are.

In response to public comments, however, CMS Monday announced they will make some significant changes in the program’s roll-out phase to refine the payment scheme and give hospitals more time to adapt. The most immediate change was a delay in the program’s start date from Jan. 1 to April 1. In another significant shift, CMS scaled back the scope of the Comprehensive Care for Joint Replacement trial from 75 cities to 67. {This is only because there are enough other places submitting to undergo a voluntary trail of this payment method (BPCI).}

It will also scrap its initial plan for paying hospitals–a plan based on whether hospitals could hit a “target price” for a given procedure without a loss of quality–in favor of a new quality score, in order to provide stronger incentives for more hospitals to improve quality. The quality score is still a work in progress, CMS said. {My initial understanding on this was that the quality score was going to reflect readmissions and complications like infections blood clots, implant failure etc. in addition to a hospital based satisfaction survey but would not be dependent on any specific rehab data (A surgical procedure for getting range of motion being the exception). So far CMS does not appear to be safeguarding therapy quality and quantity. I look for the therapy to be cannibalized the most without penalty to the hospitals.}

The agency also plans to give hospitals more time to get used to the new program before they shoulder the financial burden of costly low-quality care.

Akron General is one of a handful of hospitals that didn’t wait for the program to begin; the hospital’s administration volunteered to test alternatives to traditional fee-for-service payments through a previous Medicare trial, called the Bundled Payments for Care Improvement Initiative (BPCI).

Hospitals that didn’t volunteer for the new program were “obviously very worried” about their ability to adapt {As they should be}, says Bruce Hamory, chief medical officer at the consulting firm Oliver Wyman. Adding to their anxiety was the fact that, until Monday, no one knew precisely what Medicare would propose. CMS reviewed hundreds of comments and concerns before issuing its new rules Monday.

One Size Fits All

blue-927282_640Although most hospitals say they favor the new approach in principle, many worry about how a one-size fits all program will affect hundreds of different institutions. {Reasonable fear} In its comment on the rule, the American Hospital Association, which represents about 5,000 U.S. hospitals, was one of many groups that successfully urged the agency to delay the start date to give hospitals more time to prepare.

In Akron General, teams have coalesced around the effort to overhaul joint replacement surgery. Everyone at the hospital involved in the surgery in any way—from the pharmacy to finance, from specialty-care to physical therapy—has been trying to figure out ways to improve quality, cut costs and improve the patients’ experience.

“The nasty surprise in this whole thing is that it also includes hip fractures that requires joint replacement. That’s a different kind of patient,” Thompson says, noting that these cases are often emergencies involving older, weaker patients than those with arthritis who elect to have a joint replaced.

Each team had to rethink the entire continuum of care, from pre-operative preparation to the procedure itself, billing strategies, relationships with inpatient and outpatient extended care centers, and patient outreach.

“We did not do it on our own. We had some excellent advice,” Thompson said, noting that the hospital first turned to the Geisinger Health System for guidance and now has joined the Cleveland Clinic’s network of affiliated hospitals. Both institutions are leaders in figuring out ways to provide high-quality, cost-efficient care.

“We’ve been doing what CCJR calls for in two of our hospitals for a year,” says Dr. John Bulger, Geisinger’s chief medical officer for population health.

Key To Efficiency

knee repalcement payment modelsOne key to cost efficiency, Bulger says, is increasing the number of patients who can go home after surgery — which every patient prefers {Not true-many people really like them. I definitely advise going home because I think you can get further along if you have good teaching, but nonetheless many people like the camaraderie that SNF provides. Caregivers like it as well because it relieves them of the burden of helping and possibly having to take time off work.}–rather than into an extended-are facility. Another is to diligently gather data to make sure that any facility that takes over the care of a patient who has been discharged following surgery is also efficient, because a long stay could gobble up any savings.

Thompson said that physician charges account for about 15 percent of the cost of a joint replacement procedure. Hospital care accounts for about 40 percent of the cost. Remarkably, he said, post-acute care accounts for roughly the same percentage of the cost as the hospital stay, including surgery prix viagra en pharmacie maroc.

“That was a really surprising number when we saw these figures,” he said, calling the variation in average length of stay in different extended-care facilities, from 12 days in one center to 40 days in another in 2013, nothing less than “amazing.”

The longer the length of stay, the higher the cost, he said.

The differences in these facilities, both in quality and cost, have prompted Akron General to invite all extended-care centers in the county to come in and figure out a way to provide more efficient care. {Read cheaper, shorter care}

“Some worked with us hand-in-hand, almost as if they’re a part of our system,” Thompson said. “Some didn’t show up.”

It also prompted the hospital to sit down with patients and talk through their options, based on their growing knowledge of the facilities, the hospital’s relationship with them, the federal government’s star-rating system (one to five stars) and the length of stay reported in Medicare data.

“We clearly state that we have preferred providers,” Thompson said. “We never prevent a patient from making a choice, but we do counsel them.” {The hospital will definitely will be greasing the chute that they want the patient to slide down even more now that the amount of Medicare reimbursement is being tied to controlling costs post-hospitalization}

It will be at least a couple of months before Akron General gets its first inkling from Medicare on how well it’s doing. There are, however, a couple of indicators, not least the percentage of joint replacement patients who go home after surgery, which has risen to 60 percent from 45 percent.

And then, Thompson said, there are the reactions from patients who had one joint replaced at Akron General before the change began and another since. “Almost every single one says, ‘I can’t believe how much better this is.” {We’ll see. Count me a skeptic overall, especially for the long term}

Here is Medicare’s disclaimer on potential harms to beneficiaries on their fact sheet

Beneficiaries will benefit from protections including: additional monitoring of claims data from participant hospitals to ensure that hospitals continue to provide all necessary services; continued protection of patient data under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other applicable privacy laws; and patient notification by providers and suppliers. Further, all existing safeguards to protect beneficiaries and patients will remain in place. If a beneficiary believes that his or her care has been adversely affected, he or she can call 1-800-MEDICARE or contact his or her state’s Quality Improvement Organization (QIO) by going to http://www.qioprogram.org/contact-zones. If concerns are identified, CMS will initiate audits and corrective action under existing authority.


Michelle, PT
Michelle, PT

Michelle Stiles called "the no nonsense" therapist, by her patients, created a company called Cowboy Up Recovery after recognizing the bankruptcy of the present medical model. Too many people regard conventional medical wisdom as gospel, ignoring the subversive influences of Big Pharma and Big Medicine. She believes, Americans in general are being trained from an early age to defer to experts in numerous areas of life and losing the impulses for self-responsibility and self-reliance in the process. Over-diagnosis and over-medicating has become endemic. While thankful for the best miracles of modern medicine, she encourages people of all persuasions to listen to their bodies and seek out answers to maintain not just an absence of disease but optimal health. Her advice is: Cowboy Up, no one cares more about your health than you do.

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