Winning the CJR Game with Patient-Reported Outcome Data

CJR is a game. PRO data will help you win.

My dad advised me that if you play, play to win. For most of the nearly 400 CJR-mandates hospital facilities, there is no choice but to play, so winning the game should be the goal. By way of background, the CJR model from CMS holds participant hospitals financially accountable for the quality and cost of a CJR episode of care. Every year, CJR hospitals will receive episode target prices for MS-DRGs 469 and 470, reflecting the differences in spending for episodes initiated by each MS-DRG.

All providers and suppliers are paid under the rules and procedures of Medicare’s payment system for episode services throughout the year. At the end of a model performance year, actual spending for the episodes is compared to Medicare’s target episode price for the responsible hospital. Depending on the participating hospital’s quality of care and episode spending performance, the hospital may receive an additional payment from Medicare or be required to repay Medicare for a portion of the episode spending. Quality measures and reporting requirements include surgical complications, patient experience, voluntary submission of patient reported outcomes, and incentives for year-over-year improvement.

How can patient-reported outcome data help CJR hospitals win the game?

Many ways…

First, just showing up! By simply submitting PRO data, hospitals can earn points that may well move them into a higher category of performance that will either increase their payment or reduce their responsibility for reimbursement to CMS. But wait, there is more! The collected data will be also very valuable in improving performance and reducing costs, thus increasing the performance on other CJR metrics which, in turn, further increases payments. Stay tuned for these other benefits, but let’s start with just collecting and reporting the PRO data.

What PRO data needs to be submitted for CJR

In order to meet the requirements for successful submission of PRO data, hospitals need to submit the VR-12 or PROMIS Global-10 PRO measure; AND the full HOOS/KOOS or the HOOS JR / KOOS JR for patients undergoing eligible elective primary THA/TKA procedures. CJR hospitals only need to submit PRO data for a minimum of 50% of the eligible cases or for 50 cases, whichever is most appropriate.

CMS assigns two bonus points towards the composite quality score for hospitals that successfully submit PRO data. If hospitals do not successfully submit this data, they are not eligible for the two bonus points.

Based on the composite quality scores, CJR hospitals are given one of four grades: Below Acceptable, Acceptable, Good, or Excellent. These grades can substantially affect the hospital’s target prices for lower extremity joint replacements. Target prices increase as scores improve and thus the amount a hospital may have to repay to CMS may be reduced (hear performance penalty) or the hospital may receive a higher reconciliation payment (hear performance bonus).

It is possible in many cases to move up into a higher grade category just by submitting PRO data. CMS doesn’t consider the PRO results in determining its quality measures, only that the data has been submitted.

Here’s an example of how hospitals win by submitting PRO data

Let’s take the following situation…

Assume your hospital is in the 45th percentile of complications (Quality) and 25th percentile for HCAHPS. This would put you in the “Acceptable” Category with a Composite Quality Score (CQS) of 6.25. If your hospital successfully submitted PRO data, you would earn another 2 points putting you at a CQS score of 8.25 and at the “Good” grade level. Assuming your average historical episode price was $32,000, your hospital would improve its financial position for these procedures with CMS by over $330,000 during the CJR program. WIN!

But wait, there’s more! By collecting and submitting PRO data, the hospital wins in four more ways:

1. The information obtained by collecting PRO data will allow your hospital and its affiliated physicians to benchmark performance and identify best practices and opportunities for performance improvement in pre-, during- and post-surgery activities and processes.

2. The PRO outcomes data provides the numerator in the value equation (Value = Outcomes/Cost) that can be used as specific and credible evidence of performance in payment negotiations and network participation discussions.

3. Your PRO data can also be used in a number of valuable ways. By way of example, the pre-op data can be used to facilitate shared decision-making. The PRO encourages appropriate patients to engage in the surgery and helps set their expectations by way of functional outcomes post-procedure. Additionally, reviewing the PRO data post-procedure can educate patients on the benefits of their surgery and encourage their positive word-of-mouth advocacy to others with similar needs.

4. CMS will publicly acknowledge hospitals that have successfully submitted PROs and limited risk variable data submission by placing a symbol next to the hospital’s name on the CJR section of the Hospital Compare website. And, CMS will publicly report each CJR participant hospital’s quality measure results on the data.medicare.gov website. So, by submitting the PRO data, there will be special recognition as having done so and the likelihood that the composite quality score will be higher, which will be attractive to patients and payers alike. And this is just one way the PRO data can be used for marketing purposes by articulating the value delivered to patients using information that other patients have provided – more on this in a future article.

So, if you have to play in the CJR game, use PRO data to help you win. It is as easy as collecting and reporting. And, there are ways of collecting that do not burden either administrative or clinical staff of the practice. CODE can show you how that is done.

A Note From CODE: This is Professor’s Corner, a monthly series brought to you by CODE’s own Steve Wood, Ph.D.