Knowledge Base Article

The Comprehensive Care for Joint Replacement (CJR) Model is a mandatory model for participants in selected Metropolitan Specific Areas (MSAs) aimed at testing to see if an episode based payment approach for lower extremity joint replacement (LEJR) can incentivize hospitals to reduce cost and concurrently maintain or improve quality.

The first performance year examined LEJR episodes initiated on or after April 1, 2016 and ended December 31, 2016. The Lewin Group with partners was contracted by CMS to evaluate the impact of the Comprehensive Care for Joint Replacement (CJR) model. On August 31, 2018, CMS posted the First Annual Report to CMS’ CJR webpage.

Key Report Findings

“CJR participant hospitals were able to reduce payments through changes in utilization while maintaining quality of care. At the same time, we found no indication that CJR participant hospitals selected healthier patients to achieve these results.”

• Total episode payments decreased 3.3% ($910) more for CJR episodes than control group episodes. “At the same time, quality of care was maintained, as indicated by claims-based quality measures.”
• Average total payment reductions for CJR episodes occurred in both historically high and low Metropolitan Statistical Areas (MSAs). Historically high MSAs averaged a $1,127 decrease and historically low MSAs averaged a $577 decrease in episode payment as compared to the control episodes.
• Average Total Payments were reduced for both elective and fracture episodes relative to the control group.
• Elective Episodes were reduced by $880, and
• Fracture Episodes were reduced by $1,345

A driver in episode payment reduction by participating hospitals was by reducing institutional Post-Acute Care (PAC) payments. Specifically, fewer Inpatient Rehabilitation Facility (IRF) transfers and patients spending fewer days in a skilled nursing facility (SNF). Key ways participating hospitals changed their PAC use included the following:

• Expanded patient education efforts,
• Starting discharge planning earlier,
• Increasing coordination with PAC providers, and
• Developing preferred provider networks.

Before this model started, there was a concern that participating hospitals would pick healthier patients for participation. Claims data analysis by the Lewin Group “provided no indications of changes in patient characteristics for CJR episodes relative to control group episodes.”

“Possibly the most notable outcome during the first CJR model performance year was that statistically significant changes in utilization and payments occurred so quickly. With approximately nine months of implementation, the CJR model resulted in outcomes that are consistent with what has been achieved in other bundled payment initiatives. More time under the CJR model will help in determining if continued improvements can be achieved.”

The entire report, report appendices and a two page high level “Findings at a Glance” summary can be accessed on the CMS CJR webpage at https://innovation.cms.gov/initiatives/cjr.