- Hospitals in the Comprehensive Joint Replacement payment model saved nearly $1,000 per episode of care in the first two years while maintaining quality of care standards, according to a recent evaluation.
- Medicare likely saved money as well, although it's unclear exactly how much. The report, prepared for CMS by Lewin Group, estimates the savings at $17.4 million, but said the possible range was from a loss of $41.2 million to savings of nearly $76 million.
- Most participating hospitals received reconciliation payments in at least one of the program's first two years. Those getting the bonus tended to have higher quality scores, more episodes of care and lower patient complexity.
CJR is particularly noteworthy because it is one of CMS' rare mandatory alternative payment models. The agency has shied away from requiring participation from providers, who generally oppose being forced into programs. CMS hasn't ruled out more mandatory models in the future, but has pushed for hospitals and physician groups to voluntarily take part in existing opportunities as the industry moves ahead in the shift toward value-based care.
Some health policy experts, however, favor mandatory models, saying they offer more diverse and comprehensive data for evaluation. The encouraging results from CJR could spur support for making additional programs mandatory. The report notes the model "continues to be a promising approach."
CJR, a five-year Medicare program rolled out in 2016, pays participating hospitals for hip and knee replacements by episode of care: from admission to 90 days post discharge. It is aimed at improving care coordination and bringing down costs. Providers can be rewarded for meeting quality and spending targets or penalized for failing to achieve them.
Fewer hospitals were required to participate in 2017, however, and none were forced to in 2018. As of February 2018, a little more than 450 facilities remained in the program, down from about 800 at the program's inception.
The most recent report's finding on what hospitals were most successful with CJR is consistent with other recent research. A JAMA study from last month found safety net hospitals in the program were less likely to receive financial rewards than other facilities, which could motivate them to improve but might instead "exacerbate disparities by taking away financial resources that safety net hospitals need for improving quality."
The CMS innovation arm responsible for CJR has been aggressive in pursuing additional payment models this year. In April, the agency announced an ambitious plan for primary care coverage that includes one option with 100% downside risk. CMS has also revealed an emergency medical transportation program and teased a kidney care model.
Providers have been slow to take on risk with alternative models, but there are signs that may be changing. Recent surveys have found medical groups more willing to consider putting money on the line as programs from CMS and other payers are tested and refined.
A report earlier this year from the Government Accountability Office found providers often stop participating in a bundled payment model once they are forced to take on more financial responsibility. That high provider drop rate has borne out in the Bundled Payments for Care Improvement model, now in its second iteration.