CJR and Anesthesiology

Yes, the regulation requiring the implementation of the CJR model is relevant to these anesthesiologists because they are members of the care team of these patients within these identified hospitals. Because the work of the anesthesiologist is so critical to the financial and surgical outcomes identified as part of this regulation, their participation in this implementation process is necessary.  Without the voice of the anesthesiologist, assumptions will be made which could result in not only patient care suffering, but also an increase in overall costs either through charges for services rendered or through the repayment that would need to be made to CMS for not complying with the goals of the CJR regulation. To help meet the goals of the CJR regulation, avoid repayment to CMS, and be eligible to receive incentive payments, anesthesiologists will need to work collaboratively with their administrative and surgical colleagues to coordinate care across the entire perioperative continuum.

For all of the Inpatient Prospective Payment hospitals located within the identified 67 MSAs, participation means compliance with the CJR regulation. It means that these hospitals, within the performance years, will have the opportunity to receive a financial incentive or be subject to a CMS repayment. It also means for those who act sooner than later to implement this model within their institution, there is more time to work out any issues with not achieving desirable quality composite scores or decreasing expenditures below specified targets as there is no downside risk in the first performance year.

If your institution has been identified to participate in the CJR program, there are several key next steps that you should consider:

1. Educate yourself on the regulation – It is important to understand the regulation in its entirety.  You can access information on the CJR Model on the CMS website at the following link:
   https://innovation.cms.gov/initiatives/cjr
2. Gather data – Talk with your department heads and hospital administrators about gathering data on your organization’s current performance. This data should include outcome data (length of stay, readmission rate, complication rate, infection rate, etc.) as well as charge data (services provided during all operative periods up to 90 days post-op). This data will allow you to get a better understanding of your current status and help identify potential areas for improvement.
3. Collaborate intra- and inter-departmentally – Share the data with your colleagues within your department and with your colleagues across the organization to learn about how they are preparing for success under the program. Discuss the current performance and identify areas for improvement and efficiencies.  Determine mechanisms that would address these identified areas. Discuss potential collaborators of the care team such as skilled nursing facilities, post-acute care centers, etc.  It is critical that anesthesiologists are part of the conversation because if they are not, assumptions will be made on their behalf that could create unrealistic expectations about the services they provide.

The CJR regulation is just the beginning. CMS has indicated on several occasions that they intend to shift the percentage of Medicare payments currently paid through fee-for-service to value-based payment models, like the CJR program. In fact by 2018, the Department of Health and Human Services hopes to achieve the goal of shifting 50% of Medicare Fee-For-Service payments into value-based models. It is clear that whether or not your institution has been mandated to participate in CJR, this type of model of payment is not going away. Thus, anesthesiologists must educate themselves on this new environment not only as it relates to CJR but also as it relates to all surgical services and perioperative care that they provide. They must become familiar with the goals of CMS not only because Medicare is transitioning to this model of payment, but also because other payors are likely to follow suit. For anesthesiologists to participate in these models and have impact on overall quality, safety and costs of care, they must wield their voice in the development of these comprehensive care plans for surgical patients within their institutions. Anesthesiologists have to be viewed as an active and collaborative member of the surgical team because it is only by working together that these outcomes will be achieved.

One approach that can help prepare anesthesiologist to be an active and collaborative participants in bundled payment programs is for the practice to participate in the  Perioperative Surgical Home Learning Collaborative.  In 2014 the American Society of Anesthesiologists® (ASA®) partnered with Premier, Inc., a leading health care improvement company, to establish a national learning collaborative to develop, pilot and evaluate the Perioperative Surgical Home (PSH) model – a patient-centric, team-based system of coordinated care that guides patients through the entire surgical experience, from the decision to undergo surgery to discharge and beyond.

The First Learning Collaborative
The first iteration of the PSH Learning Collaborative brought together 44 national leading health care organizations from across the country to define and pilot the PSH model, measure its impact and develop innovative payment models to support it. Through active collaboration and shared learning, the founding members of the collaborative demonstrated that the PSH is an innovative model of care with the potential to drive meaningful and lasting change in perioperative costs, outcomes and experiences for patients nationwide. The first PSH Learning Collaborative ended November 30, 2015 and resulted in the development of 64 PSH pilots.

The Second Learning Collaborative
Building on this success, ASA and Premier will launch a second iteration of the PSH Learning Collaborative on April 1, 2016 that will run for two years. Recognizing the importance for participating in alternative payment models such as the Bundled Payments for Care Improvement (BPCI), Comprehensive Care for Joint Replacement (CJR), the Medicare Shared Savings Program (MSSP) and Accountable Care Organization (ACO), the PSH Learning Collaborative 2.0 will focus on compatible PSH implementation strategies and tactics to be successful. These strategies and tactics will also be synergistic with any health system approach to population health.