Page 22

Health System Management • January 2017

COMMENTARY HEALTH SYSTEM MANAGEMENT | JANUARY | 2017 Replacement Model (CJR). CJR is a mandatory program for all hospitals in 67 geographic regions. It provides financial incentives and penalties for hospitals to improve the coordination and quality of care, and to decrease the overall costs of care from hospital admission through 90 days after discharge for total hip and total knee replacements. The hospital can “share” the financial risk and reward with post-acute providers, including orthopedic surgeons, skilled nursing facilities, home health agencies and physical therapists. It is important to note that this program provides incentives for hospitals to control costs after the patient has been discharged. PROBLEMS ADDRESSED BY CJR The Centers for Medicaid and Medicaid Services (CMS) recognized that there is huge variation in quality and cost for total hip and knee joint replacement surgeries. According to CMS4, the total costs for a hip or knee joint replacement for hospitalization and 90 days post-discharge vary from an average of around $16,000 to $33,000 nationwide. And the costs do not correlate with quality. The cost and quality variance is due to a host of factors — including hospitalization and surgery costs, choice of post-acute care providers and care coordination. In essence, the CJR program has elected hospitals “Since we really lack a true healthcare system, it should be no surprise that we have a healthcare affordability and accessibility crisis in our country.” as the quarterback in charge of coordinating care and improving efficiency from hospitalization through 90 days post-discharge. This is done by providing financial incentives and penalties that are based on measurements of cost, quality and clinical outcomes. As an example, the hospital would be penalized if it has a higher rate of readmissions because of post-op complications, and it can share in the risk and reward of these financial incentives with all of the post-acute providers. REPEALING THE AFFORDABLE CARE ACT As this is being written in December 2016, President-elect Trump is preparing for his transition. During the campaign, he repeatedly promised the immediate repeal of “Obamacare” as one of his first official acts. In listening to the rhetoric, most of it was centered on the individual insurance mandate — not on healthcare delivery innovation. The bureaucratic wheels of the CMMI have been in motion since President Obama signed the ACA into law in 2010. It seems obvious that abandoning these efforts at innovation and returning to uncoordinated fee-for-service delivery is not feasible, and that a complete repeal of the ACA will be politically unpopular. In spite of the unpopularity of the ACA in some circles, I believe most of the programs that were initiated under the ACA will remain intact, and healthcare providers will need to adapt to the innovative healthcare delivery systems that have been developed under the ACA. REFERENCES 1. The World Bank. Health expenditure, total (% of GDP). http://data.worldbank.org/indicator/ SH.XPD.TOTL.ZS 2. Data USA. Health & Safety. https://datausa.io/profile/geo/01000US/#health 3. Centers for Medicaid & Medicaid Services website. https://innovation.cms.gov/ 4. Centers for Medicaid & Medicaid Services. Comprehensive Care for Joint Replacement Model. https://innovation.cms.gov/initiatives/CJR WEBEXTRA For statistics on the healthcare community’s expectations for the Trump presidency, read “Will the Trump Administration Improve the U.S. Healthcare System?” at www.HealthSystemMgmt.com 22 WWW.HEALTHSYSTEMMGMT.COM


Health System Management • January 2017
To see the actual publication please follow the link above