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Improving the Quality and Coordination of Care for Hip and Knee Replacements

JFK health v2

  • Location: Edison, NJ
  • Number of Beds: 498
  • HIS System: HSC

 

The Challenge

Hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries, accounting for more than 400,000 procedures and $7 billion in hospitalizations alone. With long recovery periods and large variances in rates of complications, CMS looks to solve this issue through the use of bundled payments and incentivizing hospitals.

The model, which requires hospitals to manage spend across the entire episode of care, is uncharted territory for many providers. An inherent challenge in this model is the need to build collaboration among the hospital and its physicians.

JFK Health is one of approximately 800 hospitals required to participate in the Comprehensive Care for Joint Replacement (CJR) model. CJR is a five-year program intended to hold hospitals financially accountable for the quality and cost of a CJR episode of care and incentivizes increased coordination of care among hospitals, physicians, and post-acute care providers.

This tests bundled payments and quality of care experienced during an episode of care involving hip or knee replacements. Tests began April 1, 2016 and will continue through December 31, 2020.

 

The Solution

PMMC provided bundled episode analytics and a collaboration strategy with JFK Health’s physicians to reduce spend and earn a repayment from CMS. To help build this strategy, PMMC consulted with the physicians at JFK Health By presenting a transparent, third-party perspective supported by data to which JFK’s physicians responded positively.

PMMC provided JFK with actionable analytics so the organization could quickly evaluate spend performance among its post-acute care providers and pinpoint the cost savings opportunities.

 

The Results

JFK finished $242,000 under the episode spend target and earned a repayment of $171,000 from CMS after the stop-gain limit was applied. “The data is what provides the insight for the hospitals to make decisions to hit the targets,” explained Steve Miller, JFK Health Director of Managed Care.

The retrospective recovery service achieved impressive results with PMMC’s recovery team having identified more than $2.1 million for recovery from managed care claims, of which more than $1.6 million was collected. PMMC was able to accelerate cash recovery, improve contract performance and reimbursement process and aid with negotiations.