Most people involved in healthcare—especially as it relates to Medicare reimbursements—are generally familiar with with MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) and CJR (Comprehensive Care for Joint Replacement). However, what might they might not fully understand is how MACRA and CJR are connected.
The simplest answer is that MACRA and CJR are connected by the Centers for Medicare & Medicaid’s goals for improving outcomes and reducing costs through value-based reimbursement and bundled payment models rather than the traditional fee-for-service model. A critical path for achieving this is to ensure that your hospital or clinic is prepared for better patient communication and management.
However, to more fully understand the connections between MACRA and CJR—and how patient management technology fits in—it’s best to first briefly examine these concepts and what they strive to change or improve.
Fee-for-Service vs. Value-Based Reimbursement Care Models
More thorough examinations of fee-for-service vs. value-based reimbursement care models can be found on this blog and throughout the Internet. But most simply, the key differentiator between fee-for-service and value-based care is the difference between “quantity vs. quality,” respectively.
The fee-for-service model rewards healthcare providers based how many patients and treatments a healthcare provider sees and provides (read: quantity), as where the value-based model rewards providers based on how well it treats them (read: quality)—as determined by CMS standards that include outcomes and satisfaction.
What is MACRA?
Enacted by the U.S. Congress in 2015, MACRA is a value-based payment system (also known as a “quality payment program”) to be associated with Medicare services.
More can be learned about MACRA’s quality payment program rollout for January 2017, but one of its primary features is the introduction of two payment tracks:
• Merit-Based Incentive Payment System (MIPS)
• Alternative Payment Models (APMs)
Another primary MACRA feature will be the replacement of three existing quality reporting systems with a streamlined, more effective alternative.
What is CJR?
CJR was introduced earlier this year to test a new reimbursement model that encourages and rewards efficiency and satisfaction for Medicare hip and knee replacement surgeries. Also known as as LEJR (short for “lower extremity joint replacements”), it is one of Medicare’s most common inpatient surgeries.
Putting It All Together: Linking MACRA, CJR and Value-Based Care
LEJR treatment and recovery requires care from a spectrum of caregivers, including hospitals and post-acute care. Rather than reimbursing each with the fee-for-service model, CJR utilizes a “bundled payment” model for each “episode”—which is designed to encourage all caregivers to work together towards the same goals for which MACRA is intended:
• To reduce visit frequency and in-patient procedures
• To increase satisfaction, rewards, and patient-reported outcomes
Those that are prepared for the MACRA/CJR transition will be better positioned to be rewarded economically; those that aren’t may be penalized. A crucial factor for being well positioned is to have technologies and systems that can streamline patient care coordination with workflow management.
Are you prepared to deliver and document value-based care to ensure you maximize your earning potential under reimbursement models that feature bundled payments? If not, contact a Sequence Health representative to learn about our CJR bundled payment program solutions.