Medicare Tests Bundled Services for Joint Replacement A new alternative-payment demonstration project includes audiology and speech-language pathology services in a single payment to hospitals for hip- and knee-replacement episodes of care. Here’s what you need to know. Bottom Line
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Bottom Line  |   February 01, 2016
Medicare Tests Bundled Services for Joint Replacement
Author Notes
  • Daneen Grooms, MHSA, is director of ASHA health reform analysis and advocacy. dgrooms@asha.org
    Daneen Grooms, MHSA, is director of ASHA health reform analysis and advocacy. dgrooms@asha.org×
Article Information
Speech, Voice & Prosodic Disorders / Hearing Disorders / Healthcare Settings / Practice Management / Bottom Line
Bottom Line   |   February 01, 2016
Medicare Tests Bundled Services for Joint Replacement
The ASHA Leader, February 2016, Vol. 21, 30-31. doi:10.1044/leader.BML.21022016.30
The ASHA Leader, February 2016, Vol. 21, 30-31. doi:10.1044/leader.BML.21022016.30
A new Medicare demonstration project will affect reimbursement for any health care professional—including audiologists and speech-language pathologists—who provides services to hip- and knee-replacement patients for three months after the surgery.
For audiologists and SLPs, the project—and others like it on the way—underscores the need to promote and prove the value of speech, language, hearing, swallowing and balance services.
The project, finalized by the Centers for Medicare and Medicaid Services (CMS) in late 2015, is part of the effort to slow rising health care costs by transitioning Medicare from fee-for-service to value-based payment. Under value-based payment, providers are accountable for increasing the quality of care while lowering costs.
This effort to transform health care delivery includes the development of alternative payment models, improved care coordination and transformation of primary care. The new demonstration project—Comprehensive Care for Joint Replacement Model (CJR)—is testing an alternative payment model that bundles payment and measures quality for an “episode of care” associated with hip and knee replacements.
CMS aims to link 85 percent of all fee-for-service payments to quality or value by 2016, and 90 percent by 2018. Within those goals, 30 percent of fee-for-service payments will be through alternative payment models by 2016, and 50 percent by 2018.
CJR is designed to encourage acute-care hospitals, physicians, post-acute-care facilities and other providers to work together to improve the quality and coordination of the patient’s care from initial hospitalization through recovery.

The project is designed to encourage acute-care hospitals, physicians, post-acute-care facilities and other providers to work together to improve the quality and coordination of the patient’s care from initial hospitalization through recovery.

Who participates in CJR and how does it work?
Participation in the five-year project (April 1, 2016, through Dec. 31, 2020) is mandatory for providers in 67 geographic areas (roughly 20 percent of all Metropolitan Statistical Areas). Most providers will not be able to opt out.
  • The project includes lower-extremity joint replacement or reattachment of a lower extremity procedures assigned to inpatient payment categories MS-DRG 469/470 (with/without major complications or comorbidities).

  • The “episode of care” begins when an eligible Medicare beneficiary is admitted to an acute-care hospital and ends 90 days after discharge from the acute-care hospital.

  • The acute-care hospital where the surgery takes place is accountable for all spending during the episode of care and bears all of the financial risk.

  • All related care covered under Medicare Part A (inpatient) and Part B (outpatient) during the 90 days are included in the bundled payment.

  • Facilities and other providers submit claims and receive payment via the usual Medicare fee-for-service payment systems. The bundled payment is paid retroactively through a reconciliation process.

  • In the first year of the project, the hospital is eligible for a financial reward based on its quality and cost performance during the episode. Beginning in the second year, the hospital could be required to repay Medicare for part of the costs above a certain target.

Why do audiologists and SLPs need to know about this project?
Speech-language pathology services are included in the episode of care. Part B services for communication, cognition or swallowing-related diagnoses are included because they are due either to chronic conditions whose care may be affected by the joint-replacement procedure or post-surgical care, or to complications of the procedure, such as stroke. Audiology services provided within the 90-day window are also included in the bundle.
Services provided by audiologists and SLPs may receive increased scrutiny under this model, as hospitals are now responsible for all of the financial risk.
The hospital, in an effort to control its costs and reduce financial risk, may choose to establish a network of other providers to participate in the care of joint-replacement patients. The hospital could require these providers—inpatient or outpatient rehab professionals, for example—to meet certain quality metrics and to share in any financial rewards or penalties. (Under current Medicare rules, however, beneficiaries may receive services from any Medicare-participating provider.)
Where do my services fit in this model?
The model is intended to promote care coordination by having providers work together to deliver more effective and efficient care. If, for example, spending during an episode tops the CMS-established target, the hospital will likely review the claims data to determine where efficiencies can be realized or spending reduced while preserving or improving the quality of care.
Ensuring that measurable outcomes related to communication, cognition and swallowing are included in the determination of quality care is essential. This model—part of a trend promoted by CMS and private payers—underscores the need to link interventions to meaningful functional goals that are important to patients and payers.
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February 2016
Volume 21, Issue 2