(Last Updated On: March 1, 2019)
The Center for Medicare and Medicaid Services (CMS) launched its first mandatory shared-risk, outcomes-based payment model, Comprehensive Care for Join Replacement (CJR), in April 2016. The new bundled payment model will be mandatory for nearly 800 hospitals across 67 US metropolitan areas with participants incurring downside financial risk starting in January 2017. This bundled payment model focuses on lowering overall cost and improving outcomes in the 90 day period following a lower extremity major joint replacement procedure. The two affected DRGs include:
- 469 – Major joint replacement or reattachment of lower extremity with MCC
- 470 – Major joint replacement or reattachment of lower extremity without MCC
In these bundled payment models, hospitals act as the primary risk bearing entity. All healthcare providers including physicians, Skilled Nursing Facilities (SNFs), physical therapists, etc. bill for services as usual on a fee for service (FFS) basis. At the end of the reporting period, the total expenditure for each patient is compared to a benchmark, called the target price, for the procedure. If total expenditure exceeds the target price, the hospital is penalized for the overage. If the total cost is less than the target price, the hospital, its affiliates, and CMS share in the savings.
What does this all have to do with Chronic Care Management and 99490? The answer is clear after analyzing main levers of post-discharge costs incurred after these major joint procedures. Two key drivers of cost are readmissions and post-acute care. Hospitals can only succeed in these models if their patients spend less time in SNFs post discharge and instead more time in a lower care setting (such as their own home!). In a recent survey of participating organizations, 52% of respondents said that their success in CJR was linked to their ability to reduce cost in post-acute care (see graph below).
Once patients are at home, they are in need of continuous monitoring and support – this can come in the form of non-face-to-face care coordination via Chronic Care Management and of course home health services. Staying at home avoids costly SNF charges; in fact, SNF charges represents the largest proportion of post discharge costs following lower extremity joint replacements (see graph below).
The strategy of moving patients more rapidly into lower acuity care after joint replacements was made clear during CMS’s initial pilot bundled payment model, Bundled Payment for Care Initiative (BPCI) where participants utilized home health 21% more and SNF 16% less than the non-bundled payment participants (see graph below).
Hospital resources are limited, and case management interaction with patients must start to tail off after the first few days with only sparse check-ins (if any) at the 60 and 90 day mark. Chronic Care Management (CCM) on the other hand provides a mechanism through which patients can continuously be monitored throughout the 90 day window in which hospitals can be penalized for high utilization. For this reason, CCM and care coordination can decrease the overall cost of care – CCM support can:
- Organize the required home health support to make sure that the patient is safe in their own home
- Stay on top of the patient to make sure physical therapy is being conducted, critical to a successful recovery from a joint replacement
- Decrease avoidable discharge delays (from the hospital and from the SNF) by making sure that there are arrangements in place to transition the patient to the next lower level of care
- Educate the patient on the proper discharge protocols (e.g., activity limitations, self-care, etc.)
- Increase medication adherence
- Force the patients primary care physician (PCP) to engage with the patient making sure that chronic conditions do not complicate the outcome of the procedure
- Improve patient satisfaction and overall engagement
Certain waivers available to hospitals involved in the CJR bundled payment model make it even easier for affected patients to enroll in CCM. As is widely known, one of the barriers to CCM adoption is the 20% patient copay. However, as part of CJR, hospitals can provide patients up to $1,000 to cover patient engagement IT and services such as CCM. This means that hospitals can 100% pay for all of the patient’s out-of-pocket costs for CCM services and technology.
No patient wants to live in a facility – the faster patients can safely return to their home, the better for everyone. CCM allows hospitals affected by the mandatory CJR bundled payment model to safely support their patients at home, thereby lowering SNF utilization, overall cost of care, and of course keeping patients happy and healthy.
Sources: Federal Register (80 FR 73274); https://www.advisory.com/research/financial-leadership-council/at-the-margins/2016/01/key-priority-for-cjr-reduce-post-acute-care-costs