This is clearly apparent in the Centers for Medicare and Medicaid Services (CMS) Comprehensive Care for Joint Replacement (CJR) model that went into effect on April 1, 2016. Up to this point, participation in similar bundling models has been optional, but this is the first time that CMS is requiring hospitals to participate in a value-based care initiative without the ability to opt out.
The CJR model promotes coordinated, patient-centered care for hip and knee replacements—the most common types of inpatient surgery for Medicare patients. Within the model, hospitals take on the risk for quality and cost for the entire care episode, ranging from the point of admission through 90 days post-discharge. This means that no matter where the patient goes after discharge— back home, to a hospital-affiliated post-acute facility or to some other facility of the patient's choice— and whatever care the patient receives – doctors visits, physical therapy, home health, wound care, etc. - the hospital is held accountable for patient care during the entire three month post-acute period. So, for example, if a patient has a knee replaced and discharges to a skilled nursing facility (SNF) to recover, the SNF will be paid directly from Medicare on a fee-for-service basis, but the hospital will still be held accountable for the patient's care episode up until that 90 days expires. At year's end, CMS will calculate the average episodic cost for care and either penalize or reward the hospital for holding care costs below a specific cost benchmark, set as a function of historical data and care quality. As a result, even though they cannot dictate the specific care received, the hospital is responsible for all associated costs of care that occur, even in the event of a complication, relapse or readmission.