Medicare’s new Comprehensive Care for Joint Replacement bundled payment program, covering hips and knees, starts on April 1, and it will be a new experience for most providers.

The new program emphasizes improved care coordination inside hospitals and in post-acute or home-based settings. It follows on the heels of Medicare’s Bundled Payments for Care Improvement (PBCI) program, which has been in existence since 2013.

In that program, providers and insurers assume financial risk for any losses, and share in realized savings, for treating patients suffering from one of 48 medical conditions. naviHealth has supported providers and payers participating in that program, offering a mix of analytics, clinical decision support and outsourced network management and care coordination services.


Brian Fuller Now the vendor has launched a similar service to support providers and insurers joining the joint replacement program.

Founded by investment firm Welsh, Carson Anderson & Stowe, naviHealth works with providers and insurers in a risk-based agreement where losses would be covered by each and savings would be split. While the Bundled Payments for Care Improvement program was voluntary, participation in the Comprehensive Care for Joint Replacement (CCJR) program is mandatory for providers in 67 metropolitan statistical areas.

Under the PBCI program, insurance clients of naviHealth outsource analytics, benchmarking and care coordination to the vendor, and providers initially did the same.

Over time, says Brian Fuller, vice president of value-based care at naviHealth, many hospital clients opted to bring the PBCI operations in-house. They hired their own care coordinators and integrated the vendor’s analytics and predictive modeling software in their electronic health record systems to inform development of care plans, patient needs after discharge, prospects for recovery, and identifying patients most at risk. He expects more of the same as payers and providers use the vendor to support the CCJR treatment and bundled payments program.

Lessons learned under the PBCI bundled payments program remain relevant for the CCJR program, Fuller emphasizes. For instance, hospitals over time realized they want operations and care coordinators in-house, as they participate in several value-based care programs, with more expected to come.

Hospitals also learned the importance of analytics not just to inform cost and quality issues, but to better effectively deploy resources, according to Fuller. Care coordination leaders learned that if they went to the chief financial officer asking for more coordinators, they’d better have data on why more are necessary, such as the need for additional coordinators to work with analytics-identified patients who need more comprehensive monitoring.

For example, a hospital may have seven coordinators to manage a patient population of 100,000, but they focus on the 90,000 patients with lower-level needs when there are another 10,000 with more acute needs.

Another lesson: Don’t rely on technology to be successful with value-based care. “You cannot remove the people from the technology,” Fuller cautions. “To be successful, you need a high-touch and high-tech strategy.”

Further, hospitals embarking on value-based care over time likely will experience a cultural lesson. The discharge departments usually don’t include care managers following patients after discharge; nor do the departments have personnel to manage and work with post-acute care providers. Hospitals will need to develop these functions in-house or outsource to a vendor.

(This article appears courtesy of our sister publication, Health Data Management)

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