Reimbursement Based on Value in Knee Surgery: What You Need to Know about the Medicare Access and Children's Health Insurance Program Reauthorization Act of 2015

Abstract

Health care cost is consuming a large portion of the nation's gross domestic product while placing added economic burdens on physicians and their patients. With total joint replacement being one of the early-targeted procedures in the evolving health care environment, knee surgeons will benefit from developing a critical knowledge on health care reforms and their financial implications. The Medicare Access and Children's Health Insurance Program Reauthorization Act represents a cohesive movement toward value-based payment reform and contains several unchartered rulings that require detailed attention by knee surgeons. In this article, we provide a contextual framework of health care legislation that has led to the formation of the current health policy, and present a comprehensive summary and update on the Merit-Based Incentive Payment Systems and Alternative Payment Models reimbursement models.

Keywords

health care reform - reimbursement models - MACRA - MIPS - APM

• References

• 1 Callahan CD, Adair D, Bozic KJ, Manning BT, Saleh JK, Saleh KJ. Orthopaedic surgery under national health reform: an analysis of power, process, adaptation, and leadership: AOA critical issues. J Bone Joint Surg Am 2014; 96 (13) e111
• 2 The Burden of Musculoskeletal Diseases of the United States. 2013. Available at: http://www.boneandjointburden.org . Accessed June 1, 2016
• 3 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89 (4) 780-785
• 4 Berman B, Pracilio VP, Crawford A , et al. Implementing the Physician Quality Reporting System in an academic multispecialty group practice: lessons learned and policy implications. Am J Med Qual 2013; 28 (6) 464-471
• 5 Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001
• 6 Institute of Medicine. Rewarding Provider Performance: Aligning Incentives in Medicare. Washington, DC: The National Academies Press; 2007
• 7 Edmonds C, Hallman GL. Cardiovascular care providers. A pioneer in bundled services, shared risk, and single payment. Tex Heart Inst J 1995; 22 (1) 72-76
• 8 Hackbarth G, Reischauer R, Mutti A. Collective accountability for medical care--toward bundled Medicare payments. N Engl J Med 2008; 359 (1) 3-5
• 9 The Centers for Medicare and Medicaid Services. Comprehensive Care for Joint Replacement Model; 2015. Available at: https://innovation.cms.gov/initiatives/cjr/cjr . Accessed July 22, 2016
• 10 Lavernia CJ, D'Apuzzo MR, Hernandez VH, Lee DJ, Rossi MD. Postdischarge costs in arthroplasty surgery. J Arthroplasty 2006; 21 (6) (Suppl. 02) 144-150
• 11 Rosenthal MB. Physician payment after the SGR--The New Meritocracy. N Engl J Med 2015; 373 (13) 1187-1189
• 12 Doherty RB. Goodbye, sustainable growth rate-hello, Merit-Based Incentive Payment System. Ann Intern Med 2015; 163 (2) 138-139
• 13 Bumpass DB, Samora JB. Which path will you take: how SGR repeal will change quality reporting and payment models. AAOS Now; 2016 . Available at: http://www.aaos.org/AAOSNow/2016/Jan/Advocacy/advocacy5/?ssopc=1 . Accessed December 19, 2016
• 14 Turtle L, Vyakernam R, Menon-Johansson A, Nelson MR, Soni N. Intensive care usage by HIV-positive patients in the HAART era. Interdiscip Perspect Infect Dis 2011; 2011: 847835
• 15 Van Rensch PJH, Van de Pol GJ, Goosen JH, Wymenga AB, De Man FH. Arthrodesis of the knee following failed arthroplasty. Knee Surg Sports Traumatol Arthrosc 2014; 22 (8) 1940-1948
• 16 American Hospital Association. Medicare's Bundled Payment Initiatives: Considerations for Providers. Washington, DC: American Hospital Association; 2016
• 17 Nawaz H, Edmondson AC, Tzeng TH, Saleh JK, Bozic KJ, Saleh KJ. Teaming: an approach to the growing complexities in health care: AOA critical issues. J Bone Joint Surg Am 2014; 96 (21) e184
• 18 Healey T, El-Othmani MM, Healey J, Peterson TC, Saleh KJ. Improving operating room efficiency, part 1: general managerial and preoperative strategies. JBJS Rev 2015; 3 (10) 10-20
• 19 Healey T, Peterson TC, Healey J, El-Othmani MM, Saleh KJ. Improving operating room efficiency, part 2: intraoperative and postoperative strategies. JBJS Rev 2015; 3 (10) 10-20
• 20 Kocot SL, Dang-Vu C, White R, McClellan M. Early experiences with accountable care in Medicaid: special challenges, big opportunities. Popul Health Manag 2013; 16 (Suppl. 01) S4-S11
• 21 Issar NM, Jahangir AA. The Affordable Care Act and orthopaedic trauma. J Orthop Trauma 2014; 28 (Suppl. 10) S5-S7
• 22 Tzeng A, Tzeng TH, Vasdev S, Grindy A, Saleh JK, Saleh KJ. The role of patient activation in achieving better outcomes and cost-effectiveness in patient care. JBJS Rev 2015; 3 (1) 1-27