Is the Comprehensive Care for Joint Replacement Model Going Away?

on Tuesday, 14 November 2017. All News Items | Case Management | Quality

Myth or Fact?

Recently, I have been told that the Comprehensive Care for Joint Replacement (CJR) Model is being cancelled. So, is it being cancelled? At this time, the short answer to this question is no. However, to understand what has been proposed to change, keep reading.  

Background

The CJR Model was “designed as a mandatory payment model established via notice and comment rulemaking to test the effects of bundling on orthopedic episodes involving lower extremity joint replacements.”

Final Rule CMS-5516-F implemented this new Medicare Part A and B payment model under section 1115A of the Social Security Act. Starting April 1, 2016, acute care hospitals in selected geographic areas were required to participate in this model. All related care within 90 days of hospital discharge for a lower extremity joint replacement (LEJR) procedure is included in the episode of care. CMS believes the model furthers their goals in “improving the efficiency and quality of care for Medicare beneficiaries with these common medical procedures.”

CJR, A Five Year Model

The CJR Model is set to run through calendar year 2020. The following table highlights episodes included in each performance year.

Performance YearCalendar YearEpisodes Included in Performance Year
1 2016 Episodes that start on or after April 1, 2016 and end on or before December 31, 2016
2 2017 Episodes that end between January 1, 2017 and December 31, 2017
3 2018 Episodes that end between January 1, 2018 and December 31, 2018
4 2019 Episodes that end between January 1, 2019 and December 31, 2019
5 2020 Episodes that end between January 1, 2019 and December 31, 2109

Cancellation of Advancing Care Coordination through Episode Payment Models (EPMs) and the Cardiac Rehabilitation (CR) Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Payment Model (CJR) Proposed Rule

In August of this year CMS proposed the cancellation of the EPMs and CR Incentive Payment Models. CMS also proposed the following revisions to aspects of the CJR model:  

  • Decreasing the number of hospitals that are required to participate,
  • Reconciliation and quality provisions; and
  • A change to increase the pool of eligible clinicians that qualify as affiliated practitioners under the Advanced Alternative Payment Model (APM) track.

CMS accepted comments to the proposed rule through October 15, 2017. The remainder of this article focuses on proposed revisions regarding required participation in the model.

 

Proposed Voluntary Participation Election (Opt-In) for Certain MSAs and Low-Volume and Rural Hospitals  

Currently there are 67 selected Metropolitan Statistical Areas (MSAs) across the nation where hospital participation is mandatory. CMS has proposed to continue the model on a mandatory basis in approximately half (34) of the selected geographic areas, with an exception for low-volume and rural hospitals, and continue on a voluntary basis in the other 33 areas.  

The 34 MSAs where continued participation would be mandatory were selected based on them having the highest average wage-adjusted historic LEJR episode payments. CMS indicates that “the selection of more expensive MSAs is the most appropriate approach to fulfilling the overall priorities of the CJR model to increase efficiencies and savings for LEJR episodes while maintaining or improving the overall quality of care.”

For the remaining 33 MSAs and hospitals that are low-volume or rural, CMS has proposed to provide a one-time opportunity for them to notify CMS of their election to continue participation in the CJR model on a voluntary basis (opt-in) for performance years 3, 4 and 5. CMS intends “to provide templates that can easily be completed and submitted in order to limit the burden on hospitals seeking to opt-in.”

CMS indicates that “Based on the anticipated timing for when the final rule implementing this proposal would be published, we propose that the voluntary participation election period would begin January 1, 2018, and would end January 31, 2018….Voluntary participation would begin February 1, 2018 and continue through the end of the CJR model, unless sooner terminated.” Hospitals not making a participation election would be automatically withdrawn from the model effective February 1, 2018.

The following two tables are from the proposed rule and help you understand which MSAs in the nation have been proposed for mandatory and voluntary participation including their wage-adjusted LEJR episode payments.

CJR Mandatory Participation MSAs
MSAMSA NameWage-adjusted episode payment (in $)
10420 Akron, OH $28,081
11700 Asheville, NC $27,617
12420 Austin-Round Rock, TX $28,960
13140 Beaumont-Port Arthur, TX $32,544
17140 Cincinnati, OH-KY_IN $28,074
18580 Corpus Christi, TX $30,700
20020 Dothan, AL $30,710
22500 Florence, SC $27,901
23540 Gainesville, FL $29,370
24780 Greenville, NC $27,446
25420 Harrisburg-Carlisle, PA $28,360
26300 Hot Springs, AR $29,621
28660 Killeen-Temple, TX $27,355
31080 Los Angeles-Long Beach-Anaheim, CA $28,219
31180 Lubbock, TX $29,524
32820 Memphis, TN-MS-AR $28,916
33100 Miami-Fort Lauderdale-West Palm Beach, FL $33,072
33740 Monroe, LA $30,431
33860 Montgomery, AL $30,817
35300 New Haven-Milford, CT $27,529
35380 New Orleans-Metairie, LA $29,562
35620 New York-Newark-Jersey City, NY-NJ-PA $31,076
36420 Oklahoma City, OK $27,267
36740 Orlando-Kissimmee-Sanford, FL $29,259
37860 Pensacola-Ferry Pass-Brent, FL $29,485
38300 Pittsburgh, PA $30,886
38940 Port St. Lucie, FL $30,423
39340 Provo-Orem, UT $28,852
39740 Reading, PA $28,679
42680 Sebastian-Vero Beach, FL $28,015
45300 Tampa-St. Petersburg-Clearwater, FL $32,424
45780 Toledo, OH $28,658
46220 Tuscaloosa, AL $31,789
46340 Tyler, TX $30,955
Source: Table 1 Proposed Rule CMS-5524-P

 

CJR Voluntary Participation MSAs
MSAMSA NameWage-adjusted episode payment (in $)
10740 Albuquerque, NM $25,892
12020 Athens-Clarke County, GA $25,394
13900 Bismarck, ND $22,479
14500 Boulder, CO $24,115
15380 Buffalo-Cheektowaga-Niagara Falls, NY $26,037
16020 Cape Girardeau, MO-IL $24,564
16180 Carson City, NY $26,128
16740 Charlotte-Concord-Gastonia, NC-SC $26,736
17860 Columbia, MO $25,558
19500 Decatur, IL $24,846
19740 Denver-Aurora-Lakewood, CO $26,119
20500 Durham-Chapel Hill, NC $25,151
22420 Flint, MI $24,807
23580 Gainesville, GA $23,009
26900 Indianapolis-Carmel-Anderson, IN $25,841
28140 Kansas City, MO-KS $27,261
30700 Lincoln, NE $27,173
31540 Madison, WI $24,442
33340 Milwaukee-Waukesha-West Allis, WI $25,698
33700 Modesto, CA $24,819
34940 Naples-Immokalee-Marco Island, FL $27,120
34980 Nashville-Davidson-Murfreesboro-Franklin, TN $26,880
35980 Norwich-New London, CT $25,780
36260 Ogden-Clearfield, UT $25,472
38900 Portland-Vancouver-Hillsboro, OR-WA $22,604
40980 Saginaw, MI $25,488
41180 St. Louis, MO-IL $26,425
41860 San Francisco-Oakland-Hayward, CA $23,716
42660 Seattle-Tacoma-Bellevue, WA $23,669
43780 South Bend-Mishawaka, IN-MI $23,143
44420 Staunton-Waynesboro, VA $25,539
45820 Topeka, KS $24,273
48620 Wichita, KS $25,945
Source: Table 2 Proposed Rule CMS-5524-P

The proposed rule also provides a table of low-volume hospitals located in the mandatory MSAs that would be eligible to opt-in during the voluntary election period. For the purpose of this Model, CMS defines Low-Volume Hospitals “as having fewer than 20 LEJR episodes in total across the 3 historical years of data used to calculate the performance year 1 CJR Episode Target Prices.” With the proposed rule comment period having ended in October, for now we wait to see what will be finalized.

Article by Beth Cobb

Beth Cobb, RN, BSN, ACM, CCDS, is the Manager of Clinical Services at Medical Management Plus, Inc.  Beth has over twenty-five years of experience in healthcare including eleven years in Case Management at a large multi-facility health system.  In her current position, Beth monitors, interprets and communicates current and upcoming Case Management / Clinical Documentation issues as they relate to specific entities concerning Medicare.  You may contact Beth at This email address is being protected from spambots. You need JavaScript enabled to view it..

This material was compiled to share information.  MMP, Inc. is not offering legal advice.  Every reasonable effort has been taken to ensure the information is accurate and useful.

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