Savings for joint-replacement care often come at the expense of post-acute providers.
The three-year-old bundled payment program for joint replacement has resulted in a reduction in average episode payments for Medicare. But the reductions have come largely at the expense of institutional post-acute-care settings, particularly skilled nursing facilities, not only in reduced lengths-of-stay, but in greater complexity of patients.
During the first two years, the Comprehensive Care for Joint Replacement (CJR) program resulted in decreases in average payments for lower-extremity joint replacements (LEJR) of $997, according to the Lewin Group’s “Performance Year 2 Evaluation Report.”
“Decreases in payments were due to shifts from more to less intensive post-acute care,” according to the authors of the report, which was commissioned by the Centers for Medicare & Medicaid Services. “CJR participant hospitals discharged a relatively smaller proportion of patients to an inpatient rehabilitation facility and a relatively larger proportion of patients to a home health agency than control group hospitals.
“Furthermore, CJR patients with a skilled nursing facility stay spent relatively fewer days in a SNF than control group patients. These shifts in utilization resulted in statistically significant decreases in inpatient rehabilitation facility and SNF payments, which drove the decrease in average episode payments.”
Average SNF payments for CJR episodes decreased by $508 more than for control group episodes, or 9.3% from the CJR baseline. The average number of SNF days decreased by 2.3 days more for CJR episodes than for control group episodes from the baseline (pre-CJR) to the intervention period.
Despite the decrease in overall payments, quality of care — as measured by the unplanned readmission rate, emergency department visits, and mortality — was maintained under the CJR model, according to the researchers. “Further, by the end of the 90-day episode, CJR and comparison patient survey respondents reported similar functional status gains and pain levels from before their hospitalization to after the end of the episode.”
More disheartening news for post-acute-care providers: The report found that among CJR patients discharged to post acute care, the proportion who improved their functional status during their post-acute stay decreased relative to control patients (that is, patients that were not part of the CJR program). “Orthopedic surgeons and other clinicians we interviewed and consulted were consistent in their view that home was the best place for most patients to recover,” the researchers reported.
That said, the researchers point out that the reduction in length of SNF stays might indicate that CJR patients in these settings likely had less time for improvements in functional status and pain while receiving post-acute care.
Implemented in April 2016, the Comprehensive Care for Joint Replacement model tests whether episode-based bundled payments and quality measurement for lower extremity joint replacements can lower payments and improve quality.
Under the model, an LEJR episode of care begins with the hospitalization for the surgery and extends through the 90 days after hospital discharge. All Medicare-covered items and services provided during this period, with some exclusions, are included in the episode bundle. All providers and suppliers involved in the episode continue to be paid under Medicare’s fee-for-service payment systems.
For more information visit: CMS Comprehensive Care for Joint Replacement Model: Performance Year 2 Evaluation Report, https://innovation.cms.gov/Files/reports/cjr-secondannrpt.pdf