Even as the U.S. healthcare system moves forward in its transition from being a volume-based reimbursement system to being a value-based one, patient care organizations’ levels of readiness to adapt to payment change continue to vary considerably. That includes hospital organizations’ preparedness to participate in the comprehensive joint replacement (CJR) bundled payment program under the Medicare program. That CJR bundle had been made mandatory for hospitals and for affected physicians until November 30, 2017, when senior officials at the Centers for Medicare and Medicaid Services (CMS) announced that they were reducing the number of geographic markets mandated to participate in the CJR bundle from 67 areas to 34 areas.
Still, regardless of the specific parameters of the CJR program going forward, some hospital organization leaders are skating to where the proverbial puck is headed—in other words, moving forward to master CJR bundled payments—operationally, clinically, and financially. Leaders at the Altamonte Springs, Fla.-based Adventist Health System are among the teams doing just that. Indeed, with 16 hospital facilities from their 45-hospital integrated system already involved in the comprehensive joint replacement bundled payment program, Adventist Health System leaders made the decision a couple of years ago to pursue a bundled-payment performance improvement initiative, as a natural “next step” in their organization’s development.
And that initiative has borne abundant fruit.
Combining intensive process improvement efforts with the leveraging of data, Adventist Health leaders have made dramatic gains in performance: when comparing the organization’s first six months of CJR performance Year 2 to Performance Year 1 data, the health system has seen a 19-percent decrease in 90-day readmissions, a 17-percent decrease in discharges to skilled nursing facilities, and, depending upon the diagnosis-related group (DRG), a 3- to 17-percent decrease in acute hospital length of stay, among its 16 hospitals participating in the program. AHS has received in excess of $500,000 in reconciliation payments from CMS, for its performance. And all of these improvements were made possible through the strategic leveraging of data and analytics to support continuous performance improvement, including via the use of two performance improvement dashboards—one supplied by the Charlotte-based Premier Inc., and the other, a self-developed internal dashboard that provides near-real-time data for decision-making.
Because of their pioneering work, the editors of Healthcare Informatics have chosen the leaders of Adventist Health’s bundled-payment initiative as the number-two-winning team in the Healthcare Informatics Innovator Awards Program, Providers Division.
Speaking of the origins of their initiative, Stephen A. Knych, M.D., the vice president and chief quality officer at Adventist Health, says that “Our exposure to this process around bundled payments, which began a couple of years now, came out of the mandatory CJR bundled payment program out of CMS. So that was the genesis of this; we have a number of hospitals involved in this, so the impetus to get involved in looking at care through the bundles really came to us through that. The innovation required, and the comprehensiveness, was that the program required us to look at care according to episodes defined by CMS, extending out through 90 days post-discharge, for an elective hip or knee joint replacement, with or without fracture.”
That challenge, Knych says, “was a new experience for us and for healthcare in general, when you have to bring together the resources who take care of patients across this continuum, all in one room, and literally bring together the plans of those different and disparate functions, from how you optimize the patient’s ability to be successful before and after the surgery, to how you prepare them for the surgery, do the surgery, and take care of them 90-days-post, where you’re responsible for their care,” Knych says.
What’s more, Knych adds, “The second element of challenges facing the Adventist Health organization around CMS’s mandated bundled payment program “was how this model is structured—a five-year plan. Initially, most of the target prices, what you’re allowed to spend on these people for these episodes by CMS, were primarily weighted towards local people; but then, over time, towards MSAs [metropolitan statistical areas], which cover very large regions—the six MSA regions applicable to us go all the way up to Delaware on the East Coast. That’s a very large and diverse territory. So now you have a cohort of people from across huge regions like those, that your care processes have to align with,” [with] outcomes spanning very diverse populations across that region.
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