By Rebecca Mayo, J.D.
CMS has proposed extending the CJR model for an additional three-years as well as changing the pricing and definition of episode of care.
In order to better evaluate the Comprehensive Care for Joint Replacement (CJR) model, a new proposed rule would extend the CJR model for an additional three performance years. The proposed rule would also revise the episode of care definition, the target price calculation, the reconciliation process, the beneficiary notice requirement, and the appeals process, among other things. The goal of these changes would be to reduce expenditures while preserving or enhancing the quality of care. According to CMS, the changes would save the Medicare program approximately $269 million over the additional three model years (Notice, 85 FR 10516, February 24, 2020).
CJR Model. The CJR model was established through a final rule in 2015. It is a Medicare Parts A and B payment model in which acute care hospitals in certain selected geographic areas received retrospective bundled payments for episodes of care for lower extremity joint replacement or reattachment of a lower extremity. All related care covered by Medicare Parts A and B within 90 days of hospital discharge from the procedure is included in the episode of care. Through this program, hospitals are held financially accountable for the quality and cost of a CJR episode of care and are incentivized to increase coordination of care among hospitals, physicians, and post-acute care providers. Initial evaluations for the first and second year of the CJR model indicate that the CJR model has had a positive impact on lower episode costs.
Changes. The calendar year (CY) 2018 outpatient prospective payment system (OPPS) rule removed the Total Knee Arthroplasty (TCA) procedure code from the IPO list, and the CY 2020 OPPS rule removed the Hip Arthroplasty (THA) procedure code from the IPO list. The proposed rule would change the definition of an "episode of care" to include outpatient (OP) procedures for TKAs and THAs. The beneficiary notification requirements would also be changed to require CJR participant hospitals to notify the beneficiary of his or her inclusion in the CJR model if the procedure takes place in an outpatient setting. Additionally, the waiver of the skilled nursing facility (SNF) 3-day rule and the waiver of direct supervision requirements for certain post-discharge home visits to hospitals furnishing services to CJR beneficiaries in the outpatient setting would be extended.
The proposed rule would also change the basis for the target price from three years of claims data to the most recent one year of claims data. It would also remove the national update factor and twice yearly update to the target prices that account for prospective payment system and fee schedule updates, remove anchor factors and weights, and change the high episode spending cap calculation methodology. The two reconciliation periods currently conducted two and 14 months after the close of each performance year would be replaced with one reconciliation period conducted six months after the close of each performance year. An additional episode-level risk adjustment beyond the fracture status would also be added, the high episode spending cap calculation methodology used at reconciliation would be modified, a retrospective market trend adjustment factor would be added, and the quality discount factors applicable to participants with excellent and good quality scores would be changed to better recognize high quality care.
Under the proposed rule, the Complications and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) performance periods would advance in alignment with the performance periods used for performance years one through five. The patient-reported outcomes (PRO) performance periods would also be advanced in alignment with previous performance periods and thresholds for successful submissions would be increased. The 50 percent cap on gainsharing payments, distribution payments, and downstream distribution payments when the recipient of these payments is a physician, non-physician practitioner, physician group practice, or non-physician group practice would be eliminated for the additional three performance years.
MainStory: TopStory ProposedRules CMSNews BillingNews PartANews PartBNews OPPSNews SNFNews
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