Ask the Payment Expert about... bundled payments

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Patricia Boyer, MSN, NHA, RN
Patricia Boyer, MSN, NHA, RN

Is it true that hospitals may be able to send patients to us following joint replacement surgery without a three-day hospital stay? 

Many incentive programs are being discussed related to bundled payments and waivers attached to them. The program you are referring to is the hospital Comprehensive Care for Joint Replacement Model, which is part of the innovation initiative from the Centers for Medicare & Medicaid Services. 

It would test bundled payment and quality measurement for an episode of care associated with hip and knee replacements. The purpose is to encourage hospitals, physicians and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through a 90-day recovery period. 

Part of this proposed model would allow a waiver of the three-day skilled nursing facility hospital admission requirement.  Hospitals that are in 75 Metropolitan Statistical Areas would be required to participate in this model. This means the hospital would be able to discharge to a rehabilitation stay in your facility sooner.

Now, don't get too excited! The proposed rule also would implement a limitation on the hospital that it could utilize this bundled payment initiative only for transfer to a facility rated three stars or above. This could definitely impact those facilities that have a one- or two-star rating.

This is one of many initiatives that continue to remind us of the shift in reimbursement from simply dollars to quality outcomes. Any facility that is a one- or two-star rating on Nursing Home Compare should be making plans to improve. Remember: Your healthcare survey is the baseline for the Five-Star rating and your survey history follows you for three years.