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 http://tinyurl.com/y7xm4osq.