Joint exercise

Post-acute care makes up a major part of episodic spending, leaving LTC providers to shoulder the most exposure in bundles like the CCJR, experts note.
Post-acute care makes up a major part of episodic spending, leaving LTC providers to shoulder the most exposure in bundles like the CCJR, experts note.

Some health officials believe an alternative payment bundling project for joint replacement will eventually replace a fragmented and duplicative fee-for-service program. The new model would spur caregivers toward lower costs, greater quality and accountability. 

Yet as the Centers for Medicare & Medicaid Services prepared to expand one high-profile program, therapy providers and their long-term care partners had mixed feelings about it.

(Just as this issue was going to press, federal officials approved a delay of the expansion, from July to October, and possibly longer.)

It was a different picture back in January 2013, when CMS unveiled its Bundled Payments for Care Improvement initiative, which the National Association for the Support of Long Term Care hopefully called “an innovative new payment model.”

Rewards questioned

The Comprehensive Care for Joint Replacement bundling program began its first of five performance years on April 1, 2016. As proposed by CMS, acute-care hospitals in selected geographic areas are required to participate in all eligible lower-extremity joint replacement episodes that begin at one of the selected hospitals.

These facilities and providers assume financial and performance accountability for complete episodes of care, each of which includes services required within 90 days of hospital discharge. 

Despite what many feel are logical parameters and expectations, the nascent effort has had its share of detractors.

Now four months since the penalty-free period has ended, and on the heels of a plan to expand the CCJR program to hip and femur fractures in July, hospitals are feeling a bit overwhelmed. Meanwhile, collaborative-hungry therapists are frustrated and nursing homes with less-than-stellar Five-Star quality ratings are wondering how they will cover anticipated reimbursement dips from the potential loss of hospital referrals.

That's not to say providers give the program a thumbs-down. 

“The overall feeling among physical therapists is positive, but they are still just trying to figure it out right now,” says Roshunda Drummond-Dye, a spokeswoman for the American Physical Therapy Association. “There is a lot of activity around just trying to figure out what patients are being treated, and analyzing data and figuring out the best clinical care pathways to treat those patients.”

Thriving on chaos has always been the norm in healthcare, but rehab and skilled nursing facilities are grumbling increasingly louder about a bundling program that many believe favors hospitals. Other providers also have begun to question whether the program is skimping on care. 

Some providers are quick to point to what they view as the upsides of the CCJR program.

Participating has provided greater efficiencies, more frequent treatments and shorter lengths of stay while allowing his company to more quickly see post-operative patients, says Matthew Mesibov, PT, GCS, a clinical physical therapist specialist with Centrex Rehab. 

Overall, communication about patients' health status have improved, if only in the sense that “the patient won't disappear and be left on their own after discharge,” National Association for the Support of Long Term Care Executive Vice President Cynthia K. Morton, MPA, adds. Some things, meanwhile, tend to fall through the cracks, notably hospitals failing to notify SNFs that a transferred patient is in a CCJR bundle until two to three days into their stay, she adds.

LTC vulnerable

Meanwhile, Morton says the program serves only to illustrate how “exposed” the long-term care industry is. 

“While hospitals are financially accountable for the total cost of the episodes, post-acute care providers may have the most exposure in the CCJR and similar payment bundles,” she explains. “This is because post-acute care is a major component of total per-episode spending. For joint replacement episodes, post-acute care is 37 percent of spending for the episode.”

One particular concern for NASL's members who participate in the CCJR bundle is staffing. 

“When accepting patients in the bundles, a facility must be able to provide rehab therapy seven days a week,” Morton says. “It can be tough in certain markets to have therapy provided on weekends, but it's essential.”

Morton also is concerned that hospitals that manage the bundle will focus their energies on reducing the costs of the total bundle, including the costs in the acute phase, “but in many cases, it is post-acute settings that are seen as the most obvious opportunity [for cutting costs]. Usually, this is in the skilled nursing facility care or home healthcare.”

While nursing homes and their therapy partners could lower their cost exposure, hospitals could still “arbitrarily attempt to simply avoid referring patients as an effort to control episode costs.”

Providers concerned

Meanwhile, some see the payment bundling concept needing a lot of work. Until issues are resolved, therapy providers face thinned margins, points out Hugh Hall, administrator of West View Nursing & Rehabilitation Center in Warwick, RI.

“The concept of creating relationships of service between providers for the benefit of the patient is absolutely the right course,” he says. “The idea of providing service in the least costly setting is also a great idea. I think the weakness is ultimately that is not what happens. It has created an opportunity for the center of the bundle, the hospital, to attempt a savings that drops mostly to their bottom line.

“At this point, while I am willing to accept risk in this process, the hospitals take all the risk and they reap all the benefits of the bundling,” he adds. “Those adversely affected by this process are the people pushed home who really need to spend some time in a skilled setting.”

While APTA is positive about the opportunities CCJR affords its members, Drummond-Dye remains guarded.

“We are concerned about the possible over-dominance of hospitals or physicians to isolate independent physical therapy practices, so we've been very closely monitoring the fraud and abuse laws and some of the waivers that have been extended there ... we don't want an unfair playing field for our providers,” she notes.

Morton also sees therapy services at risk of being diminished. In fact, she asserts that patients are getting “less therapy” in the SNF as a result of CCJR.

“Ultimately, it is the hospital that is making the final decision as to whether or not to stay in the SNF or for the patient to proceed home,” a decision that could be negative for seniors with joint replacements having co-morbidities such as diabetes or chronic obstructive pulmonary  disease.

Yet another issue is procedural chaos inside the hospitals themselves. One NASL member told Morton that “even though CCJR has been in place since last April, hospitals in our market have been extremely slow to develop any type of procedure surrounding the bundle. In fact, we had gone to many of the hospitals to discuss CCJR only to be told that our knowledge for the bundle was significantly ahead of theirs.”

Lack of collaboration?

Stacey Hodgman, MS, RN-BC, CMAC, division vice president of clinical integration and care navigation for RehabCare, applauds the collaborative component outlined in the new payment models. Many healthcare providers have formed partnerships as a result to support alternative payment models. 

“Rehabilitation therapists are now experiencing an improved team approach to support outcomes of patients undergoing joint replacement,” she adds. 

Not everyone shares Hodgman's assessment. “One of the biggest hurdles is being able to collaborate with those hospitals that are essentially in charge of the episodic model, and making sure we're able to collaborate with them in a meaningful way,” Drummond-Dye says. She hopes that will change this year, noting that APTA is beginning to see more hospitals reach out to physical therapy providers, outpatient and post-acute care “to either put together formal agreements with them or figure out ways they can collaborate. 

“I think that's probably why you haven't heard a lot of information, because our constituency is just starting to get some skin in the game and really figure out what's going on from that perspective,” she adds. 

“A lot of outpatient therapists and post-acute care providers have really just started ramping up their marketing to hospitals because they were, in fact, trying to figure out their capacity to handle patients and what level of risks they could assume within these models. So on that end, I think they've been hesitant to just jump in and sign a contract and say we'll be liable for a percentage of the penalty payments back to Medicare because they had to figure out what their individual business practices were and what they could handle.”

Drummond-Dye says if the CCJR program expands to include new bundled payment models around cardiac care, there will be even more challenges and opportunities.