Beginning April 1st, ~800 hospitals are being held accountable for the quality and total cost (all Medicare FFS Part A and B costs of care during the hospital stay as well as Medicare costs for 90 days post hospital discharge) of care provided to Medicare fee-for-service beneficiaries for lower extremity joint replacement (LEJR) procedures (MS-DRG 469 and 470).
- Retrospective, two-sided risk model with hospitals bearing financial responsibility
- CMS will establish a target price for each participant hospital based on blend of hospital-specific and regional episode data
- CMS will make reconciliation payments to hospitals that achieve quality outcomes and cost efficiencies (relative to target prices).
- CMS assigns an individual Quality Performance Score for each participant hospital based on the hospital’s performance percentile relative to the national distribution
- Hospitals must meet minimum threshold on 3 quality metrics to be eligible for reconciliation payments
Composite Quality Score
Key score component and weights:
A hospital’s quality composite score impacts their payment in two ways:
- Hospitals with a “below acceptable,” overall composite score are ineligible to receive reconciliation payments
- CMS will apply an automatic discount to the target cost of care. Hospitals with excellent quality composite scores can reduce their effective discount percent to 1.5%; hospitals with poor scores will see their discount percent increased to 3%.
PRO REPORTING BONUS
Out of the 20 total Composite Score points, hospitals can earn 2 bonus points or 10% of their score by submitting required Patient Reported Outcomes (PRO) and selected pre- and post-operative data elements initially for 50% or 50 total eligible patients (increases to 80% in the final performance period).
The first performance period in 2016 is a 2 month window between July 1, 2016 and August 31, 2016 where pre-operative baseline PRO collection is required on 50% or 50 total eligible patients.
HOW CAN OM1 HELP?
OM1, formerly Better Outcomes, provides the first enterprise-level patient-reported and clinical outcomes solution that:
- Automates PRO collection with a mobile first/consumer engaging approach
- Generates robust and valid condition scores for the hospital, provider and the patient
- Works standalone or fully integrated with major EMRs
- Provides predictive capabilities that will lower risk and improve financial performance under CJR