Home Health & Hospice Week

HHAs won’t always be the right fit for CJR patients.

Why is Medicare focusing its first mandatory hospital-post-acute bundling demonstration on lower extremity joint replacement? Just take a look at the stats.

Absolute spending: “Hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries and can require lengthy recovery and rehabilitation periods,” the Centers for Medicare & Medicaid Services says in a release about the Comprehensive Care for Joint Replacement Model that launches April 1. “In 2014, there were more than 400,000 procedures, costing more than $7 billion for the hospitalizations alone.”

Comparative spending: “The quality and cost of care for these hip and knee replacement surgeries still varies greatly,” CMS maintains in the release. “And the average total Medicare expenditure for surgery, hospitalization, and recovery ranges from $16,500 to $33,000 across geographic areas.”

Quality-wise, “the rate of complications like infections or implant failures after surgery can be more than three times higher for procedures performed at some hospitals than others,” CMS points out. Lack of bundling, which is an incentive to coordinate care, “leads to more complications after surgery, higher readmission rates, protracted rehabilitative care, and variable costs,” CMS declares.

SNFs Won’t Always Lose Out

One of the highest variations in CJR episode costs comes from skilled nursing facility utilization, says consultant Shawn Matheson with Salt Lake City, Utah-based Leavitt Partners, in a post on the firm’s website. “SNFs have a consolidated billing system (Resource Utilization Groupers, RUG’s), which provides natural incentive to have a long Length of Stay (LOS) for Medicare rehab patients,” says the consultant who was a former nursing home executive director.

Good news: CJR will incentivize hospitals to push for home care for discharged LEJR patients, due to the lower cost setting, experts predict.

But don’t expect to receive all of the patients who currently go to SNFs. “In a CJR bundle, SNFs remain a very integral and key partner in the orthopedic rehab continuum, as a patient on a rehab high RUG receives very intense therapy (720 minutes a week),” Matheson expects. “But LOS needs to be as minimal as possible.” And quality outcomes must still be high.

“While HHAs are less expensive Per Patient Day, they deliver less minutes of therapy per week in a person’s home than is possible in the inpatient SNF environment,” Matheson points out. “Less minutes of therapy can equate to lower patient gains in therapy.”

When HHAs do receive patients who would otherwise go to the SNF, those patients may stay in the hospital two or three days longer than they would for a SNF discharge, Matheson expects. A delayed discharge will be outweighed by the savings on an HHA versus SNF setting for the remainder of the 90-day CJR episode.