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Medicare’s CJR Initiative

Jeffrey Krempec, MD

Jeffrey A. Krempec, MD

Medicare’s Comprehensive Care for Joint Replacement model seeks to lower the cost of total hip and total knee arthroplasties by incentivizing hospitals to optimize patients’ care paths. The CJR initiative also aims to improve hospital systems and delivery of care. The five-year initiative went into effect April 1, 2016, with financial implications for noncompliance effective April 2017. “What this means,” said Jeffrey A. Krempec, MD, an orthopedic surgeon with Drisko, Fee & Parkins and chair of North Kansas City Hospital’s CJR compliance committee, “is that hospitals that perform total joint replacements have one year to reduce CJR expenditures and meet benchmark targets.”

Patient Expectations

Primary care physicians can directly influence outcomes by educating patients and setting appropriate expectations. Historically, people looked at what post-surgical services insurance carriers were willing to pay for and then expected those services. “Now, the goal is to optimize patient care while being cost conscience,” Dr. Krempec said. For example, not every patient is an appropriate candidate for post-operative care at a skilled nursing or inpatient rehabilitation facility, or even for in-home physical therapy. If patients are otherwise medically healthy, they should be discharged to home.

“Patient-generated quality of care and experience data shows patients prefer to recover at home,” said Dr. Krempec, “Families should be engaged at the onset to determine what postoperative care is appropriate for their family and establish an at-home support system.” By setting appropriate post-surgical expectations from the beginning, the entire care team delivers a consistent message and builds trust with the patients throughout their medical encounter.

Reviewing Protocols

Achieving and maintaining CJR compliance requires a paradigm shift . To help healthcare providers guide patients to the appropriate care, the CJR committee is educating everyone in the continuum of care, including physical therapists, home health staff, PCPs, pre-operative nursing and surgeons.

The committee is also reviewing pre-operative planning, including:

  • Costs of orthopedic implants
  • Surgical techniques
  • Pharmaceutical protocols
  • In-patient therapy protocols

In addition, the committee is evaluating the use of advanced imaging studies. MRI and CT scans are not only costly, but they often are not beneficial to orthopedic evaluations. Orthopedic surgeons encourage PCPs to contact them before ordering pre-exam tests to help determine which test are needed.

Medicare Discharge Disposition

Risk-stratifying Patients

Additionally, risk-stratifying patients and optimizing their health before surgery directly impacts post-operative issues and complications, readmissions and ED visits. PCPs are encouraged to share bio-statistics and educate patients about what they can do to optimize and improve their healthcare episode. Patient education should include discussions about controlling hemoglobin A1C, weight loss and smoking cessation.

Dr. Krempec encourages referring physicians to consult with their surgeon if a patient is having post-surgical issues. Addressing concerns early creates a better patient experience and reduces ED visits and hospital readmissions.

The Future

The goal of CJR is in no way to limit or compromise patient care, the goal is to utilize the most appropriate level of care for each patient’s unique needs. Dr. Krempec believes Medicare’s CJR initiative – and the resulting cost reductions – will lead to similar programs across the healthcare spectrum. Physicians can be proactive by optimizing patients’ care paths, being cognizant of costs and educating consumers so they become active participants in controlling healthcare costs.