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 New Joint Replacement Study Shines Light on Readmissions, PAC Opportunities

Leavitt Partners on Aug. 24 released research that shows patients included in the Centers for Medicare & Medicaid Services’ (CMS) Comprehensive Joint Replacement (CJR) bundle program are at the most risk of readmissions during the first 30 days after discharge from a hospital.

Leavitt found that 5.1 percent of CJR patients returned to the hospital within the first 30 days, while 2 percent returned between days 31 and 60, and less than 2 percent in the following 30-day increments, up to a cumulative total of 11.7 percent of patients returning by day 180.

This is one of many factors affecting hospital strategies on how to cut readmissions and which post-acute care (PAC) providers to include on their networks, the report’s authors said.

The CJR program, which is going through proposed changes offered by the Trump administration to make provider participation less mandatory and more voluntary, has increased scrutiny on hospital readmissions and their causes.

To help answer why readmissions occur, Leavitt undertook its new study, “Why Patients Readmit: Using a Readmission Curve to Identify Patients at Risk for Hospital Readmissions Following Hip and Knee Replacement Surgery.”

The key findings that emerged included not only that patients are at the most risk for readmission within the first 30 days of discharge, but returns to the hospital setting are more common with five chronic conditions: anemia, chronic kidney disease, viral hepatitis, pressure and chronic ulcers, and chronic pulmonary disease and bronchiectasis.

“As hospitals work toward lowering costs and improving quality, they need effective strategies to reduce readmissions,” Leavitt said.

The way the CJR works is to encourage care coordination from hospitalization through rehabilitation. Leavitt said traditionally, the cost of care for hip and knee replacements from surgery to recovery has ranged from $16,500 to $33,000 depending on the geographic region.

“A hospital discharge of MS-DRG 469 or 470—major joint replacement with and without complications, respectively—triggers the bundle, which extends for 90 days post-discharge and includes all hospitalization and post-acute care costs,” the report said.

Readmissions have usually been assessed in 30-, 60-, and 90-day intervals, and CMS’ programs have accepted the 30-day paradigm when designing bundles.

“Models 2 and 3 of CMS’ Bundled Payment for Care Initiative (BPCI) allow providers to elect their episode time period from an option of 30, 60, and 90 days,” Leavitt said. “CJR defines an episode of care as 90 days from discharge.”

And, according to the CJR final rule, CMS selected a 90-day period in order to cover the full joint replacement recovery period for most beneficiaries and to promote coordination among providers.

But, Leavitt said, looking at the 90-day interval for readmissions limits the understanding of why patients are readmitted to the hospital, resulting in the study’s preference to examine readmissions on a curve along the entire time frame.

The results, they said, are that hospitals have to create more effective strategies to trim readmission rates, putting chronic conditions, discharge locations, and events in the hospital in separate categories to analyze.

The CJR is designed to encourage hospitals to reduce widespread cost variation in hip and knee replacements, as well as post-operative hospital readmissions, which could have a big on PAC providers pushing to become preferred partners in value-based care models.

Nathan Smith, a specialist for Leavitt, tells Provider that this closer scrutiny will increase as the CJR program progresses. “Given that full risk [in the CJR program] doesn’t begin until Jan. 1, 2018, the providers in the 34 mandatory markets won’t notice any change from what was already coming, which is additional scrutiny from hospitals for patients being treated for hip and/or knee replacements,” he says.

Right now, hospitals are likely probing the PAC patient experience and the ways in which different PAC providers are correlated with higher readmission rates, and subsequently higher total costs.

“This could eventually lead to a narrowing of networks, where hospitals are shifting PAC care to specific PAC providers with a better track record and are working to improve hospital readmission rates,” Smith says.

In addition, this could also turn into larger proportions of PAC providers entering into accountable care arrangements with hospitals, wherein they might start bearing some of the financial risk stemming from PAC.

Read the report at

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