Is the Comprehensive Care for Joint Replacement Model Going Away?
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.
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 Year||Calendar Year||Episodes 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|
|MSA||MSA Name||Wage-adjusted episode payment (in $)|
|12420||Austin-Round Rock, TX||$28,960|
|13140||Beaumont-Port Arthur, TX||$32,544|
|18580||Corpus Christi, TX||$30,700|
|26300||Hot Springs, AR||$29,621|
|31080||Los Angeles-Long Beach-Anaheim, CA||$28,219|
|33100||Miami-Fort Lauderdale-West Palm Beach, FL||$33,072|
|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|
|37860||Pensacola-Ferry Pass-Brent, FL||$29,485|
|38940||Port St. Lucie, FL||$30,423|
|42680||Sebastian-Vero Beach, FL||$28,015|
|45300||Tampa-St. Petersburg-Clearwater, FL||$32,424|
|Source: Table 1 Proposed Rule CMS-5524-P|
|CJR Voluntary Participation MSAs|
|MSA||MSA Name||Wage-adjusted episode payment (in $)|
|12020||Athens-Clarke County, GA||$25,394|
|15380||Buffalo-Cheektowaga-Niagara Falls, NY||$26,037|
|16020||Cape Girardeau, MO-IL||$24,564|
|16180||Carson City, NY||$26,128|
|20500||Durham-Chapel Hill, NC||$25,151|
|28140||Kansas City, MO-KS||$27,261|
|33340||Milwaukee-Waukesha-West Allis, WI||$25,698|
|34940||Naples-Immokalee-Marco Island, FL||$27,120|
|35980||Norwich-New London, CT||$25,780|
|41180||St. Louis, MO-IL||$26,425|
|41860||San Francisco-Oakland-Hayward, CA||$23,716|
|43780||South Bend-Mishawaka, IN-MI||$23,143|
|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
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.