CMA Alert – Joint Replacement Model Undermines Care; OTC Hearing Aids Legislation Passed; More
Care is Compromised Under CMS’s Comprehensive Care for Joint Replacement (CJR) Model: A Case In Point
On a Friday this past March, “Ms. T”, a 70-year old Medicare beneficiary in Albuquerque, underwent total knee replacement surgery in the hospital. To her shock, she was transferred by van to a skilled nursing facility (SNF) the next day while still very sick from the anesthesia and pain medication she had been given. She had to wait until Monday to be evaluated for therapy. On Monday evening, after Ms. T had completed just one physical therapy session, the staff met and determined she was “self-sustainable” and would be discharged home on Wednesday.
Ms. T knew she would not be able to safely manage at home, where she lives alone and without help. All of her movements were weak and painful. Even in the SNF she was not permitted to get out of bed without close supervision. Of the six basic activities of daily living (ADL), she was only able to feed herself, and required hands-on assistance with bathing, dressing, toileting, transferring (walking) and continence. She could not don and doff the compression hose ordered for her leg. Plus, she was still vomiting from the pain medication, having some difficulties breathing (she has asthma), and her blood pressure and blood sugar levels (she is diabetic) were notably elevated.
On Tuesday Ms. T. received an hour each of PT and OT, the last sessions she would receive at the SNF. The next day, she was asked by the facility, “When is someone going to pick you up?”, and issued a second notice that she would be financially liable for her stay. Although she was terrified to leave the SNF, she paid a car service to take her home and struggled in severe pain over the next four days, unable to get out of bed let alone care for herself. Over the next month, she received ten (10) in-home PT sessions from the SNF’s rehabilitation affiliate. After that, it was up to her to arrange for outpatient therapy, although she still could not drive.
Why Did This Happen?
Through her own research, Ms. T. learned that her county is located in one of 67 geographic areas in which Medicare recently began testing an alternative payment model for hip and knee replacements. Approximately 800 hospitals in the selected geographic areas have been required to participate in the Comprehensive Care for Joint Replacement (CJR) model. Participant hospitals are accountable for the quality and cost associated with their traditional Medicare patients’ lower extremity joint replacements and related care during the 90-day post-discharge episode For each hospital, the model sets target episode prices that include related services paid by Medicare Part A and Part B. At the end of a performance year, actual episode spending for a hospital will be compared to the applicable Medicare target episode prices for that hospital.
Hospitals also receive a composite quality score based mainly on their performance and improvement on two quality measures: Total Hip Arthroplasty/Total Knee Arthroplasty (THA/TKA) Complications measure and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measure. Notably, the HCAHPS survey measure is not specific to THA/TKA diagnosis-related groups or even limited to Medicare beneficiaries, but evaluates patients’ perceptions of their entire hospital experience based on a minimum of 100 completed surveys. A hospital can also receive two points toward its composite quality score just for submitting patient-reported outcomes (PRO) and limited risk variable data, neither of which is required. Depending on a hospital’s cost and quality performance, it may receive an additional payment from Medicare or may have to repay Medicare for a portion of the episode spending above the target price.
The stated aim of the CJR model is to increase quality and lower costs by providing incentives for hospitals to work more closely with physicians, SNFs, home health agencies, and other providers to coordinate a patient’s whole episode of care. Note that this aim says nothing about the patient’s medical condition or recovery. The theory is that such payment reform will promote a patient-centered approach and lead to improved outcomes, shorter recovery times, and fewer complications and readmissions. This was certainly not the case for Ms. T.
In its comments to the final rule establishing the CJR model, the Center for Medicare Advocacy expressed concern that the model would, in practice, reduce patient care to the least intensive settings, regardless of an individual’s needs, and inappropriately limit access to Medicare coverage for medically necessary medical care and rehabilitation. Unfortunately, this was Ms. T’s experience under the CJR model, as evidenced by her abbreviated hospital and SNF stay, and the lack of care coordination, inadequate discharge planning, and minimal receipt of therapy. She strongly believes that her protracted recovery is attributable to these deficiencies.
Ms. T received no prior notice that her procedure would fall under the CJR program. If anything, she understood from her surgeon that she would be in the hospital 2-3 days and at the SNF for at least two weeks, and would not be sent home until she was independent in ADLs. This plan and expectation was reinforced by what she had heard from others who had undergone knee replacements and had begun to functionally recover by week 4 post hospital discharge. Ms. T believes that had she been allowed to stabilize post-surgery and receive a course of rehabilitation in the SNF, she would now be finished with outpatient physical therapy. Without that baseline of covered intensive therapy in the SNF, she is now facing heavy out-of-pocket medical expenses as she has exceeded the Medicare outpatient therapy cap and still requires physical therapy. She is at least a month or two behind in reaching the average range of motion for females.
The CJR demonstration may work if properly coordinated and implemented – when providers at all levels of care are communicating well with patients and each other. To ensure this is happening, CMS should carefully scrutinize episodes of care provided under the model that diverge from the established clinical standards and guidelines for joint surgery, post-surgery, and rehabilitation management. In the same vein, greater oversight is needed to ensure that provider profits do not come before optimal patient experiences and outcomes. The CMS CJR model must do more to actually coordinate quality care, evaluate patient satisfaction with the program, encourage best practices, and hold providers accountable. Only by doing so can CMS safeguard Medicare beneficiaries’ interests in obtaining necessary, quality health care.
To date, Ms. T has received no survey seeking her evaluation of the institutional care she received under the CJR Program.
 The SNF 3-day qualifying inpatient stay waiver is available to participant hospitals for CJR payment episodes that initiate on or after January 1, 2017.
 Update: On August 17, 2017, CMS announced a proposed rule to reduce the number of mandatory geographic areas participating in the CJR model from 67 to 34. CMS proposes to allow hospitals in the 33 remaining areas to participate on a voluntary basis, and also to make participation voluntary for all low volume and rural hospitals in all of the CJR geographic areas. The proposed rule (CMS-5524-P) can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection. Public comments are due by October 16 at 11:59 pm EST.
 The full text of the CJR model final rule is available at: http://federalregister.gov/a/2015-29438.
 The CMS Innovation Center has published answers to frequently asked questions about the CJR initiative at: https://innovation.cms.gov/Files/x/cjr-faq.pdf.
Over-the-Counter (OTC) Hearing Aid Act Signed into Law
The Over-the-Counter (OTC) Hearing Aid Act was signed into law this week, making certain types of hearing aids available over the counter to those with mild to moderate hearing impairment. This Act was part of the Food and Drug Administration (FDA) Reauthorization Act.
The Act requires the FDA to issue regulations containing safety and labeling requirements for this new category of OTC hearing aids, while also maintaining existing safety, labeling, and manufacturing protections for medical devices and applying them to OTC devices.
An estimated 70% of Americans with hearing problems between age 65 and 84 are not using hearing aids, primarily because of the high costs. Hearing aids are not covered by Medicare or most private insurance plans. Out-of-pocket costs for one hearing aid averages over $2,000; most individuals need two hearing aids, doubling the cost.
This is a positive development in meeting a serious need for seniors. Thanks to our partners at the National Committee to Preserve Social Security and Medicare, and other organizations for their advocacy on this crucial issue.
The bill is available at: https://www.warren.senate.gov/files/documents/3_21_17_Hearing_Aids_Bill_Text.pdf
A factsheet about the bill is available at: https://www.warren.senate.gov/files/documents/3_21_17_Hearing_Aids_One_Pager.pdf
Severe Harm if ACA Cost-Sharing Payments End
In an effort to make insurance offered through the Exchanges more accessible to individuals, the Affordable Care Act (ACA) authorized cost-sharing reductions (CSRs), which are payments to insurers to offset discounts that plans must give to lower-income individuals. They are integral to making coverage on the Exchanges more affordable, and to stabilizing the insurance market. Outside of efforts to repeal the ACA, some policymakers are seeking to undermine the exchanges by, among other things, ending CSR payments. While the Trump Administration has announced it will make CSR payments for August, the president has repeatedly threatened to cut off such payments, leading to significant instability at a time when insurers are facing upcoming deadlines by which they must announce their rates for 2018.
On August 15, 2017, the Congressional Budget Office (CBO) released a report outlining the impact of stopping CSR payments. The Center on Budget and Policy Priorities (CBPP) released a new blog, CBO: Severe Harm If Trump Halts Health Cost-Sharing Payments, analyzing the CBO’s findings that ending CSR payment would lead to increased costs for insurance and raise the number of uninsured. Key findings include:
- “Stopping CSR payments would raise federal budget deficits by $6 billion in 2018 and $194 billion over the next ten years, relative to current law, due to increased costs for the ACA’s premium tax credits for low- and moderate-income people to offset their rising premiums”
- Marketplace premiums for “silver-level” plans would rise by 20%, on average, in 2018. Premiums for such plans would be 25% higher in 2020 and thereafter, relative to current law.
- Marketplace insurers in some states would withdraw from or not enter the marketplaces in 2018. As a result, the share of the nation’s population living in areas with no marketplace insurers would rise to 5% in 2018, up from less than 0.5% under current law.
- The number of uninsured would rise by 1 million in 2018, relative to current law.”
Instead of sabotaging the ACA, Congress and the Administration should do all that is necessary to shore up the Exchanges, including continuing CSR payments.