CJR-X gets value-based care wrong

OPINION:

As physicians and conservatives, we have spent our careers working toward the same goal: improving patient care while being responsible stewards of taxpayer dollars.

That is why we support efforts to improve healthcare value. Innovation has helped drive better outcomes, improve coordination and reduce unnecessary spending.

Yet experience has taught us that lasting reforms work best when they are shaped by patients and providers, not imposed by Washington. So the recent proposal to expand the Comprehensive Care for Joint Replacement model, or CJR-X, deserves closer scrutiny.

At its core, this is about whether federal regulators should be able to impose sweeping changes to Medicare payment policy without congressional approval and whether those changes are in the best interests of patients, providers and taxpayers.

The proposal from the Center for Medicare and Medicaid Innovation, known as CMMI, would require hospitals in communities nationwide to participate in a mandatory payment model.

Under CJR-X, a hospital is held financially responsible for the total cost of a patient’s care for a lower extremity joint replacement for 90 days after surgery. This includes treatment delivered by clinicians and facilities that the hospital neither owns nor controls.

If that bundle of spending exceeds a target set by Medicare, the hospital would pay back the difference.

When Congress created CMMI, it gave the agency authority to test new payment models, not a blank check to mandate participation in experimental programs.

Congress reserved for itself the authority to make major changes to Medicare. We know this firsthand because, between us, we have helped write and oversee the nation’s healthcare laws.

Yet there is a more basic problem. A demonstration is supposed to have an endpoint: You test it, study it and decide what worked. This demonstration has no end date.

CJR-X would begin in late 2027 and continue permanently, changing how Medicare pays for joint replacement without Congress ever voting on it. Even the agency’s current mandatory bundled payment model is set to run for a fixed five years and then end.

A program with a start date and no finish line is not an experiment; it is a national payment policy enacted by regulation. Decisions of that magnitude belong to Congress.

Value-based care is good policy. We have both spent years working to improve quality, strengthen care coordination and move the system toward better patient outcomes. Still, there is a real difference between testing a model with willing participants and imposing a single mandatory design on every hospital.

The Trump administration was right to recognize that distinction in 2017 when it scaled back mandatory payment models in favor of a more flexible approach. That decision reflected the belief that innovation works best when providers can determine what works for their patients.

As physicians, we know that medicine is rarely one-size-fits-all. We have been in operating rooms and treated thousands of patients. Every case is unique, and every treatment plan deserves thoughtfulness.

We have sat with patients and their families to decide, case by case, what recovery should look like. Two patients who undergo the same procedure on the same day may need very different care, and the judgment about what each needs belongs to the physician and the patient, not to a payment formula.

That reality is particularly important when it comes to CJR-X. Joint replacement care looks very different today than it did a decade ago. Many routine procedures have moved to outpatient settings, and the patients still requiring inpatient care are mostly older, sicker and more medically complex.

In other words, the remaining inpatient population is precisely the group most likely to require additional services and higher spending. A payment model that assumes otherwise penalizes the surgeons and hospitals who take on the most difficult cases.

Yet this proposed mandatory model would hold hospitals financially accountable for spending decisions that often occur after a patient leaves the hospital and frequently involve providers the hospital does not employ or control.

In many communities, orthopedic surgeons practice independently. Follow-up care is delivered by separately owned facilities. Home health agencies operate under their own management structures. Hospitals can coordinate care, but they cannot dictate decisions made by independent providers.

When providers are held responsible for factors outside their control, patient care can suffer.

Conservatives have long believed that competition produces better ideas than central planning and choice produces better results than mandates. Those principles also apply in healthcare.

If a payment model works, providers will participate. If it needs refinement, it should be improved before being expanded. That is how innovation should work.

Patients, providers and taxpayers deserve reforms that encourage innovation, not mandates that replace it.

• Dr. Thomas E. Price, an orthopedic surgeon, most recently served as the 23rd secretary of health and human services. Dr. Larry Bucshon, a cardiothoracic surgeon, most recently served as the U.S. representative for Indiana’s 8th Congressional District.