AHA recommends changes to joint replacement payment model
The AHA on Sept. 8 expressed support for the Comprehensive Care for Joint Replacement (CCJR) payment model, but urged the Centers for Medicare & Medicaid Services (CMS) to “provide hospitals with the necessary tools to be successful under the program and appropriately balance the risk versus reward equation.”
In comments to the agency, the AHA said the CCJR model could help further hospital efforts to transform care delivery through improved care coordination and financial accountability,
The proposed model, announced by the agency on July 9, is designed to improve patient outcomes from hip and knee replacement surgery. Under the proposed rule, the hospital in which the surgery takes place would be responsible for cost and quality of care from the time of surgery through 90 days after the procedure, or an “episode” of care. Then, based on cost performance and the quality of care delivered, the facility would either receive a financial reward or be required to repay Medicare for a portion of the costs, according to CMS.
In its comments on the proposal, the AHA urged the Department of Health and Human Services to waive the Physician Self-Referral Law and Anti-Kickback Statute with respect to financial arrangements formed by hospitals that comply with the proposed rule’s requirements.
“As proposed, any financial arrangement or agreement under the CCJR model that implicates fraud and abuse laws would not be protected unless it falls under an existing exception or safe harbor,” noted AHA Executive Vice President Tom Nickels. “That is an unacceptable risk for hospitals, whose participation in this program would be mandatory.”
The AHA also urged CMS to delay the program’s start date and downside risk to give hospitals “adequate time to put in place the care processes and procedures necessary to achieve success in the program.” In addition, the association urged CMS to restrict the program to elective hip and knee replacement episodes, and incorporate a risk-adjustment methodology. And the AHA recommended changes to more appropriately balance provider risk and reward.
Hip and knee replacements are some of the most common surgeries that Medicare beneficiaries receive. In 2013, there were more than 400,000 inpatient primary procedures, according to CMS.