On July 9, 2015 CMS proposed a project to test bundling on patients with total hip replacements and total knee replacements called Comprehensive Care for Joint Replacements (CCJR). This proposal was based on the CMS Innovation centers Bundled Payment for Care Improvement (BCPI)-Model 2.
What is bundling? In a nutshell, a bundle is like a time-expanded DRG (diagnostic related group). Currently, while payments are per DRG in the hospital. If a patient goes to a SNF, then payment to the SNF is per day, and therapy is paid via inclusion in the per diem RUG rate as determined by intensity (minutes per week) of therapy services. Home therapy also is paid via inclusion in the case rate for each patient. If the patient is readmitted to the hospital, then payment to the hospital will depend upon the DRGs related to that admission.
What is a Model 2 Bundle? In the CMS Bundling Model 2 -the entire case , from the day of hospital discharge for a knee replacement and 90 days thereafter is considered an “episode.” A prearranged target price for the episode is calculated based upon factors such as the historical performance of bundling participants (how much their costs averaged in a hospital, SNF, readmissions, etc.), and the typical costs for this “episode” in the region for a knee replacement. Provider participants agree ahead of time to be in the bundling project which encourages acute care and post-acute collaborations to redesign care. For example, participants may include the hospital, a physician practice and a skilled nursing facility.
The participants would be paid the traditional way, and the case would be followed by some type of coordinator across all settings over the 90 days post hospital discharge. All costs associated with the patient would be totaled at the end of the episode, and this is considered the actual spend. If the costs run under the estimated cost, then participants could receive additional payments called “gain share,” essentially rewarding them for efficient care. If the costs run over, then they could be liable for a portion of the loss called “down side risk.”
Bundling programs encourage participants (hospitals, physicians, SNFs, etc) to work together to hold down costs and promote efficiency. Generally, it is not possible to make money in a bundling program without making sure that readmissions (which are the largest cause of cost overruns) are kept to a reasonable rate, and by making sure that therapy and SNF time is not longer than it needs to be. By having participants share in the results, they in effect are incentivized to come up with ways to redesign care in order to make everything work, including the transitions between care settings. Some of the bundling arrangements actually include quality measures and incentives to payments which are tied to performance on these measures.
The power of the bundle is the ability to force organizations to come to the table to work together. In a bundling situation the hospital has to work together with the SNF, for example, to make sure that the transition of care is smooth and that the transfer of medical information is both timely and complete. Providers now are rewarded for catching a change in condition in the SNF before it results in a readmission to the hospital. Now there is reason for emergency personnel to have clear communications with the SNF when evaluating a patient who is in the midst of a bundling episode.
What is CCJR and how does it vary from previous bundling programs? Golden Living has been participating in several CMS bundling initiatives, including both Model 2 and Model 3 Bundled Payment Initiatives. CCJR is a new CMS bundling program patterned after Model 2 which covers total knee and hip replacements. As currently proposed, the hospital will be the “convener” and will accept all of the potential risk. The hospital leadership will set up a network where some amount of gain can be shared with “collaborators,” such as hospital physician practices, post-acute providers such as the skilled nursing facility, inpatient rehab facilities, LTACHs and other services such as outpatient therapy organizations.
Are the CCJR details set? The above details represent what CMS has proposed. Comments to the program are being sought, the deadline for which is Sept 8, 2015. CMS will then make a decision as to the final details. CCJRs are proposed in 75 different regions (called metropolitan statistic areas, or ‘MSAs’) in the US. They are slated to begin January 1, 2016.
What does this mean for my LivingCenter and my practice? Hospitals will look to partner with post-acute providers and organizations which have a good patient care track record. Specifically, in order to do better per episode, they naturally will seek out organizations with lower rates of complications, better quality measure results, lower rates of hospital readmissions, strong functional outcomes and lower lengths of stay. They are likely to develop a “preferred” provider network. In order for GLC to be included in such networks, we must be clear on our willingness to cooperate with the hospital in order to optimize length of stay, minimize preventable rehospitalizations and to avoid complications. If not, they will seek a different place to send their joint replacement patients.
Hospital discharge choices may be influenced by this program. It is likely that hospitals will take the cost of post-acute care venues into account when deciding where a patient should go at the end of their inpatient stay.
Will this expand to more than just joint replacement? Ultimately, this sort of payment arrangement is likely to cover many more clinical conditions. CMS has set a goal of 30 percent of payments being based on Value Based initiatives such as ACOs and/or Bundled Payment Initiatives by the end of 2016.
Will I still get paid to see my patients? Yes. You still should be able to bill and be reimbursed as you always have in the SNF. If your LivingCenter is participating, it is likely that you’ll be asked to work together with the leadership on care “redesign” efforts in order assure good performance relative to some of the outcomes mentioned above. Payments made to you and other physicians are included in the total cost of the episode.
Will my practice get to be a collaborator and share in potential gain? The current CCJR proposal does not include SNF attending doctors, although we will be recommending to CMS that this be allowed.
What if I’m already participating in a Bundling (BCPI) program? Ongoing Bundling Programs take precedence over CCJR. Those Bundling Programs will not change.
Where can I learn more about this?
General bundling information – http://innovation.cms.gov/initiatives/bundled-payments/
Specific information about CCJR – http://innovation.cms.gov/initiatives/ccjr/
If you have further questions, please feel free to contact me.
 RUG – Resource Utilization Group – RUGs are categories that represent levels of resource need in LTC settings, mainly to facilitate Medicare and Medicaid payment. They are assigned to patients based on information from the Minimum Data Set (MDS)
 Bundled Payment Care Initiatives (BCPIs) have several models. In Model 2, which was described in the example, the episode includes the hospital stay and ends 90 days after discharge to the SNF. In Model 3 the episode is triggered by a hospital stay, but actually begins with admission to the SNF.