Adopting — and Adapting — to the CJR Payment Model, Part I:

Before the Inpatient Stay

Sarika Aggarwal, MD, MHCM, Chief Medical Officer, SVP, Population Health, xG Health Solutions, March 4, 2016

Effective April 1, 2016, all hospitals paid under the inpatient prospective payment system (IPPS) for lower extremity joint replacement procedures (including hip and knee replacements) will be accountable for total cost and quality of care provided to Medicare fee-for-service beneficiaries. Of course, improved efficiencies, outcomes and patient experiences have long been a primary goal for hospitals. What’s different now?

Under the Centers for Medicare & Medicaid Services’ (CMS) final rule for the Comprehensive Care for Joint Replacement (CJR) payment model, hospitals will be held accountable for the costs and quality of care provided during the inpatient hospital stay — and for 90 days after discharge from the hospital (including a patient’s stay at a rehabilitation center or skilled nursing facility (SNF), and while recovering and rehabilitating at home). This window of accountability can be divided into four distinct periods:

  • Pre-admission (or the ambulatory period)
  • Surgical procedure and inpatient stay
  • Post-acute care in a rehab center or SNF
  • Home care and rehabilitation

 

For Hospitals, this final rule means that their responsibility for and financial risks related to patient care and cost-containment have increased exponentially, into areas that were not typically under their sphere of influence. Under former CMS payment models, hospitals were held accountable only for services provided during the pre-operative, operative and post-operative inpatient stay; today, the hospital must exercise greater control over the services provided by rehab facilities, visiting nurses, physical therapists and others.

Over several xGPulse blog posts, we will explore some of the issues facing hospitals, and identify tools and solutions that can help them achieve the goals of the CJR program. In Part 1, we will take a look at the pre-admission experience.

Before a candidate for joint replacement enters the hospital, a number of pre-existing factors, many of them longstanding, lifestyle-related issues, can affect the success of his or her joint-replacement procedure. These include:

  • Smoking history
  • Obesity
  • Pre-existing and/or chronic medical conditions
  • Cognitive and physical functional status
  • Post-surgery quality of life goals and expectations

 

With this in mind, and in order for hospitals to succeed under CJR, they must take a broader view of population health. They must work closely with primary care physicians, orthopedic surgeons and other specialists long before the patient enters the hospital for the joint-replacement procedure. Together with the broader healthcare community, hospitals can improve overall population health and better identify those patients who are good candidates for joint replacement surgery. For those who are high-risk candidates, the hospital can work with physicians and other medical professionals to address and ameliorate pre-existing conditions so that the patient is better prepared for a procedure at some point in the future.

Drawing on more than 20 years of proven, Geisinger-developed solutions, xG Health offers a number of products, including ProvenCare, ProvenHealth Navigator and other tools, that have a demonstrated, positive impact on population health and can help your organization succeed under the CJR model.

To receive future updates on the CJR program, click here.



Rocky Edmondson RN, BSN, MBA, CCRN
Senior Director, Bundled Payments, Care Redesign and Management Advisors, xG Health Solutions

Rocky Edmondson is the Senior Director of Bundled Payments for Care Redesign and Management Advisors at xG Health Solutions. Rocky has been involved in workflow redesign, program implementation, and analytic evaluation of Bundled Payment Programs across the country, and he coaches Hospitals, Health Systems, Post-Acute Providers, and Physician Groups on how to successfully implement care redesign in the Bundled Payment for Care Improvement (BPCI) and CJR Programs.

Rocky’s passion is helping people to understand the intricacies of Bundled Payment Programs. He has a talent for teaching people how to cut through all the noise and just do the things that matter to be successful in these programs.

Rocky holds an Associate’s Degree in Nursing from the University of Hawaii Maui, and a Bachelor’s Degree in Nursing and a Master’s Degree in Business Administration (MBA) from Boise State University.

Prior to joining xG Health Solutions, Rocky was the Southeast Region Director of Clinical Operations for Remedy Partners, overseeing program design, implementation and analytic evaluations for Bundled Payment Programs. Prior to embarking on a career in Bundled Payments, Rocky was a Registered Nurse for 18 years, working in a number of positions within Critical Care. Before becoming a Nurse, Rocky was an Institutional Broker at Merrill Lynch and advised a number of healthcare systems and large corporations on cash management strategies. In addition, Rocky has started several businesses and provided consulting for small business startups. Rocky served in the U.S. Marine Corps as a Recon Marine.

Janet Comrey RN, BSN, MHSA
Director, Population Health Solutions, Geisinger Health System

Janet Comrey, RN, BSN, MHSA has over 30 years of diversified nursing and leadership experience at Geisinger Health system and currently serves as Director of a small department embedded within Population Health. One of her key roles is managing the Bundle Payment for Care Improvement (BPCI) program since January 2014 earning an overall positive net payment reconciliation to date. Janet also serves as the coordinator for Project Achieve at Geisinger which is a national PCORI funded study related to patient’s perceptions of transitions of care.

Janet received her nursing education through Geisinger’s diploma program, her BSN through Bloomsburg University, and later earned her graduate degree from Marywood University. During her tenure at Geisinger she taught quality improvement methodology and facilitated improvement teams the Geisinger Quality Institute. She is currently enrolled in the Institute for Healthcare Improvement Advisory program.

Professional memberships include Sigma Theta Tau, Phi Kappa Phi, American Society for Quality.

Andrew Blackmon, MBA, MHS
Chief Sales and Business Development Officer

Chief Sales and Business Development Officer Andrew Blackmon, MBA, MHS, has more than 18 years of experience in healthcare product sales, marketing, and strategy.

Before joining xG Health, Andrew was vice president of sales for population health and risk management solutions at McKesson. He came to McKesson through acquisition of MedVentive, an early population health vendor. Before MedVentive, he served as vice president of enterprise solutions development at MedAssets. He is a past president of the Georgia chapter of HIMSS, and he has held strategy and planning positions at PricewaterhouseCoopers and Orlando Health.

Andrew has an MBA and a Master’s of Health Science from the University of Florida Warrington, College of Business, and a Bachelor of Arts degree in Psychology from Rollins College.

Holly Barbella, RN, MBA

Risk Coordinator, Geisinger Health System

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Earl P. Steinberg, MD, MPP
Chief Executive Officer

Earl P. Steinberg, MD, MPP, is a nationally recognized expert in healthcare quality improvement and serves as xG Health’s chief executive officer. Earl also is an adjunct professor of Medicine and of Health Policy and Management at Johns Hopkins University and a member of Blue Cross/Blue Shield Association’s National Medical Advisory Panel.

Before joining xG Health, Earl was executive vice president of Innovation & Dissemination, and chief, Healthcare Solutions Enterprise at Geisinger Health System.

Before joining Geisinger, he was senior vice president for Clinical Strategy, Quality & Outcomes at WellPoint, Inc., the largest commercial health insurer by membership in the US, and president and CEO of Resolution Health Inc. (RHI), a leading healthcare data analysis company that provides innovative quality improvement and cost reduction services to health plans, employers, pharmacy benefit managers, and disease management companies.

Before joining RHI, Earl spent six years as vice president of Covance Health Economics and Outcomes Services Inc., director of its Quality Assessment and Improvement Systems Division, and co-director of its Outcomes Studies Group. He also spent 12 years on the full-time faculty at Johns Hopkins University, where he was professor of Medicine and of Health Policy and Management and director of the Johns Hopkins Program for Medical Technology and Practice Assessment, and four years on the Federal Physician Payment Review Commission. He co-chaired the Institute of Medicine’s panel on Standards for Development of Trustworthy Practice Guidelines.

Earl has received many awards, including the Henry J. Kaiser Family Foundation Faculty Scholar Award in General Internal Medicine (1984), the “Outstanding Young Investigator” Award from the Association for Health Services Research (1988), and a Special Presidential Visionary Award from the National Kidney Foundation (NFK) (2004) for his work as the scientific director of the NKF’s landmark Kidney Disease Outcomes and Quality Initiative, which produced more than 250 clinical practice guidelines for management of patients with end-stage renal disease. He also is a fellow of both the American College of Physicians and AcademyHealth, and he has published more than 125 articles in peer-reviewed journals.

Earl received his AB from Harvard College (summa cum laude), his medical degree from Harvard Medical School, and a Master of Public Policy from the Kennedy School of Government. He performed his residency training in internal medicine at Massachusetts General Hospital.