CMS Scrutinizes Joint Replacement Outcomes

Some would say it was a matter of inevitability. Others will hail its arrival as a much-needed shift away from pay-per-procedure and toward pay-for-quality.

On April 1, 2016, CMS began the testing phase of its Comprehensive Care for Joint Replacement (CJR) model, a new payment structure for episodes of care related to total knee and total hip replacements under Medicare.

According to CMS, Medicare beneficiaries received more than 400,000 knee and hip replacement surgeries in 2014. While these procedures enjoy massive appeal because of their ability to improve overall quality of life, complications and costs vary significantly.

The CJR testing phase is planned to last five years and will be implemented in 67 metropolitan statistical areas, including almost 800 hospitals.

One such region is the New York Metropolitan area, which includes Northwell Health, consisting of 21 hospitals and nearly 450 outpatient practices. Fourteen of its hospitals will participate in the CJR pilot project, becoming responsible for both the cost and overall quality of care delivered to Medicare patients for 90 days after their procedures.

“The discharge from the hospital is not the end of the medical journey for the patient, but marks the beginning of the next phase of recovery,” remarked Zenobia Brown, MD, MPH, medical director at Northwell Health Solutions.

CMS is billing the CJR pilot project as a departure from the traditional “fee-for-service” model of care, in which providers are paid whenever they treat a patient. The bundled payment system holds hospitals accountable for all costs incurred during the entire episode of a patient’s care — from admission, to surgery, inpatient hospital stay, rehabilitation, and other care delivered after the patient leaves the hospital.

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