Under the Arch – Archway Health’s Bundled Payment Musings We spent some time talking through the CJR quality metrics with a few customers recently and came away with some thoughts on how to approach them in the first few quarters of the CJR program. Below is a brief description of how these metrics work along with some of our thinking.
Brief CJR Quality Metrics Overview
The CJR quality metrics are made up of the three following components:
- Hip & Knee Risk Standardized Complication Rates (RSCR)
- HCAHPS Survey Scores
- Voluntary Submission of Patient Reported Outcomes
Hip & Knee Risk Standardized Complication Rates (RSCR) - These scores have been around for a while and they measure post discharge complications like AMI, hospital-acquired infections, and surgical site infections. They can be calculated and tracked quarterly from the claims data CJR participants receive from CMS. The impact these scores have on CJR reimbursement, however, will be assessed annually by CMS and will be based on how the hospital’s RSCR rates compare to all of the other hospitals in the country. The RSCR reporting period for 2016 CJR patients is April 1, 2013 through March 31, 2016. Once the scores are available CMS will force rank all of the hospitals in the country and create a Quality Performance score of 5.5 (30th percentile) to 10 (90th percentile).
We communicated with CMS and learned that they will do this forced ranking when they reconcile each year. The RSCR rate is the highest weighted CJR quality metric and represents roughly 50% of a hospital’s Composite Quality Score. It is worth noting that these complications are relatively rare for most US hospitals, making RSCRs a pretty volatile measure with just a few complications in a performance year shifting a hospital’s ranking and Quality Performance Score significantly.
HCAHPS - These scores have also been around for some time. They are based on customer satisfaction surveys conducted by CMS of representative samples of all of a hospital’s patients, not just joint patients. This information is aggregated by CMS on an annual basis for each CJR performance year. The performance period for the 2016 reconciliation is from July 1, 2015 through June 30, 2016. These results cannot be calculated from the claims data, but they will ultimately be available on the Medicare Compare website. Once CMS calculates the data, they force rank all of the hospitals in the country, similar to the RSCR process described above, and then give each CJR hospital a score based on where they rank (90th percentile, 80th, etc.). Depending on what decile a hospital is in, the hospital earns Quality Performance Points ranging from 4.4 on the low end (that's for the 30th to 40th percentile) up to 8 points for the 90th percentile. This score will only change once per year and will be calculated prior to when the annual CJR reconciliation occurs. The HCAHPS score rate is the second-highest weighted CJR quality metric and represents roughly 40% of a hospital’s Composite Quality Score.
Patient Reported Outcomes - This measure is the only new metric that has been created for the CJR program. It is optional, and it’s worth roughly 10% of a hospital's CJR Composite Quality Score. Patient Reported Outcomes can also be helpful for continuous improvement and marketing purposes beyond the CJR program. For CJR, CMS is also only monitoring if a hospital submits pre- and post-operative patient-reported data—the actual results of the surveys don't impact a hospital’s score. The 2016 pre-operative data collection period is July 1 through August 31, and hospitals need to report PROs on the lower of 50 patients or 50% of their joint patients this year to qualify. In all there are about 20 sets of information that need to be collected from each surveyed patient pre- and post-surgery.
Composite Quality Score
Once CMS calculates all of these Quality Performance Points they will give each CJR hospital a score ranging from 0 to 20. Any hospital below 4.0 will earn zero reconciliation dollars, even if they have created savings for the CJR patients in their program. Providers with a score above 13.2 will only have to give a price discount of 1.5%; hospitals with a score between 4 and 6 will give a discount of 3.0%; and those between 6 and 13.2 will give a discount of 2.0%. This structure is outlined in the table below:
Net Value of the Quality Metrics
Put simply, hospitals that are in roughly the top 60th percentile on RSCR and HCAHPS scores will have the opportunity to earn about $400 more per case than hospitals that are in the 30th percentile. Hospitals that are below the 30th percentile in both their RSCR and HCAHPS will be ineligible to earn any savings in that CJR performance period.
In assessing the potential impact of submitting the PROs we ran some scenarios and found that the 2.0 Quality Performance Points that can be gained by submitting the PROs will improve a hospital’s discount rate about 10% of the time. When this does occur the discount reduction will add roughly $65 to $130 in savings per case.
What Has Changed?
One of the first things we like to do when CMS creates a new program is to evaluate the rules and program design to assess what has really changed and what has essentially stayed the same. Understanding the big changes helps us determine what providers should focus on operationally to maximize the chance for success within the program.
In talking to hospitals it seems that not that much has really changed with respect to Risk Standardized Complication Rates—the RSCRs and HCAHPS. It is not new for hospitals to have people, data, and processes focused on trying to keep their complication rates low, and improving their customer experience ratings through HCHAPS. The CJR quality structure may create more emphasis on these metrics, but in the case of RSCRs and HCAHPS, the CJR program has not created whole new quality, data gathering, or performance improvement requirements.
Patient Reported Outcomes, on the other hand, require the collection and submission of a completely new set of metrics created for the CJR program. These metrics will require hospitals to collect over twenty data points from and about patients before surgery and 9 to 12 months after surgery. Overall we believe this is a great step for improved quality and patient care and we are big fans of using PROs to differentiate provider performance and help patients choose the best doctors and hospitals to meet their needs. And in fact, we are building tools within our Carelink tool and performance tracking dashboards to make it easier for hospitals to collect and track this data.
That said, we are not recommending that CJR hospitals implement PRO programs in the first year of the program unless they already have a PRO program and infrastructure in place. We’re making this recommendation for several reasons:
- PROs are voluntary;
- The financial impact is likely to be less than the cost of collecting the data;
- There are many other areas of focus, in our experience, that will have a bigger short-term impact for CJR patients.
Given the design of the quality metrics and the overall structure of the CJR program, we are working with our CJR customers to focus their CJR-related efforts on the big ticket items that can have an immediate cost and performance impact, while recommending that they continue to do what they have been doing to improve complication rates and HCAHPS scores.
For Medicare major joint patients, the short-term big impact activities generally include things like the following:
- Joint Class training
- Pre-surgical assessments and care plan development
- Pre-surgical home visits for high-risk patients
- 90 day patient tracking
- Surgeon engagement and gainsharing
- SNF network development
In our experience improvements in these areas can quickly lead to enhanced patient satisfaction, reduced readmissions, fewer SNF and IRF days, and thousands of dollars in savings per case. Once these practices are implemented we suggest then moving to build an effective PRO program.
Please send us any thoughts or comments you have on what we’re posting. We’d love to hear from you.