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.

The Implementation of Lean Six Sigma Principles to Improve the Value of Care Delivery for Total Joint Arthroplasty Patients: The Perioperative Institute of Surgical Excellence Experience

“…As the program grows under the Centers for Medicare and Medicaid Services monitoring and supervision, the weight of these categories and other specifics to the program will fluctuate over the next few years based on data-driven assessment and continuous feedback. 3…”

“…In an attempt to cater to the shifting focus on efficiency of care delivery models, in which optimal quality and minimal waste and cost are the end goal, the concepts of Lean Six Sigma (LSS) and service lines were introduced and popularized. 2,3 A musculoskeletal service line aims to align the interest of all stakeholders involved in the musculoskeletal care delivery continuum, via defined, well-designed processes. 4 Through agreement and establishment of baseline parameters and variables constituting a target for improvement, institutional alliances, aimed at quality improvement and cost reduction, can be achieved.…”

“…5,6 Stemming from the manufacturing industry, Lean, which was developed by Toyota, identifies and eliminates waste through process mapping and redesign, whereas Six Sigma, developed by Motorola, aims to specifically minimize errors to a six standard deviation level, which is equivalent to 3.4 defects per million products. 3 In combination, LSS methodology constitutes an approach to quality improvement that has a proven track record in healthcare literature in improving value of care delivery by detecting and preventing errors, whereas reducing waste and process variations. 3…”

“…3 In combination, LSS methodology constitutes an approach to quality improvement that has a proven track record in healthcare literature in improving value of care delivery by detecting and preventing errors, whereas reducing waste and process variations. 3…”

“…2 MIPS is designed to be a budget-neutral program, with high-performing providers receiving bonuses offset through the penalties to underperforming providers. 3 Performance is assessed via a composite score derived from four categories: quality (45%), resource utilization (15%), advancing care information (25%), and clinical practice improvement activities (15%). As the program grows under the Centers for Medicare and Medicaid Services monitoring and supervision, the weight of these categories and other specifics to the program will fluctuate over the next few years based on data-driven assessment and continuous feedback.…”