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Ambitious CMS Hip-Knee Pilot Program on Track for April Start

By Kerry Young, CQ Roll Call

February 16, 2016 -- Medicare appears on track to start in April a test program that will make about 800 hospitals financially responsible for how well people fare after knee and hip replacements, despite pleas from industry groups for more time to prepare for the major reimbursement change.

The Centers for Medicare and Medicaid Services (CMS) seems unlikely to offer further concessions on its Comprehensive Care for Joint Replacement (CJR) program after having last year shifted away from the original January 2016 start date. The draft proposal for the CJR program was first unveiled in July 2015. 

The debut would contrast somewhat with how some other federal rules on medical payments have been handled, said Todd Johnson, chief executive officer of HealthLoop, a Mountain View, California-based company that has developed tools for automating ways for doctors to check in easily with their patients. The implementation of the ICD-10 medical billing codes, for example, was repeatedly delayed due to objections from doctors before taking effect last year.

"In terms of new regulations, that's pretty darned quick coming through CMS. Hospitals have gotten used to constant delay" on agency proposals, said Johnson, whose firm developed a kit to help hospitals prepare for the CJR program.

Officials at CMS "say they are going to do something but then they push it back, they push it back, they push it back," Johnson said. "Not in this case."

The agency has stuck with a requirement that hospitals within 67 selected regions participate in the hip-and-knee program, despite complaints from providers. The 67 areas of the country sweep in hospitals in places such as New York, San Francisco and Los Angeles and greater Orlando, Florida, with limited exceptions. Under the program, the hospitals could get higher pay if their patients do well in the 90 days following hip and knee replacements, or have to repay Medicare if their patients are judged to have fared poorly.

With the program, CMS is taking on a fairly common medical procedure for people on Medicare, with more than 400,000 procedures performed on those enrolled in the program in 2014 at a cost of $7 billion. Medicare officials long have been concerned about poor results in some regions, with rates of complications and infections three times higher at some hospitals than others. Expenses for surgery and recovery vary as well, ranging from $16,500 to $33,000, according to CMS.

The speed with which the CJR was handled reflects a drive by the Obama administration to try to leave a stamp on Medicare in its final months, according to Health and Human Services Secretary Sylvia Mathews Burwell. She has said there was a "very aggressive timeline" to get the draft CJR program out for review last year, as the department wanted it up and running in 2016.

"It's important for us to get the bundle done and start implementing before we go," Burwell said at a Feb. 5 pen and pad session with reporters.

The hip-and-knee replacement project is one of the major initiatives led by the Center for Medicare and Medical Innovation (CMMI), which was created by the 2010 health law. The goal of CMMI is to improve the medical care provided to senior citizens and the disabled by moving away from Medicare's longstanding fee-for-service approach. Under the fee-for-service model, Medicare has given the same reimbursement regardless of whether the care was poor or exemplary. In the future, hospitals, doctors and other providers of health care will need to pay the same kind of attention to the results delivered to patients that participants in the hip-and-knee model must, Burwell said.

"It tells people where we, as a large payer, are going," Burwell said. "It's something that is helpful for them."

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