CJR Model: Three - Year Extension and Changes to Episode Definition and Pricing and Additional Relevant Rulemaking - Comprehensive Care for Joint ...
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Comprehensive Care for
Joint Replacement Model
CJR Model: Three-Year Extension and Changes to Episode
Definition and Pricing and Additional Relevant Rulemaking
Comprehensive Care for Joint
Replacement Model
May 2020
Audio available through device speakers
Webinar Agenda
• Welcome
• Meeting Logistics
• Proposed Rule Presentation
• Interim Final Rule With Comment Period Presentation
• Inpatient Prospective Payment System FY 2021 Proposed
Rule Presentation
• Public Comment Submission Instructions
• Announcements & Reminders
Comprehensive Care for
Joint Replacement Model 2
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Comprehensive Care for
Joint Replacement Model 3
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Comprehensive Care for
Joint Replacement Model 4Comprehensive Care for
Joint Replacement Model
Comprehensive Care for Joint Replacement (CJR) Model:
Three-Year Extension and Changes to Episode Definition and
Pricing
Heather Holsey, JD, MS
Matthew Fox, MPP
Sarah Mioduski, JD
Center for Medicare & Medicaid Innovation
Centers for Medicare & Medicaid Services
5Disclaimer
This presentation was current at the time it was published or uploaded
onto the web. Medicare policy changes frequently, so links to the source
documents have been provided within the document for your reference.
This presentation was prepared as a service to the public and is not
intended to grant rights or impose obligations. This presentation may
contain references or links to statutes, regulations, or other policy
materials. The information provided is only intended to be a general
summary. It is not intended to take the place of either the written law or
regulations. We encourage readers to review the specific statutes,
regulations, and other interpretive materials for a full and accurate
statement of their contents.
Comprehensive Care for
Joint Replacement Model 6CJR Proposed Rule
• CMS published the proposed rule, ‘Medicare
Program: Comprehensive Care for Joint Replacement
Model Three-Year Extension and Changes to Episode
Definition and Pricing’ on February 24, 2020
• Public comment period closes at 5:00 pm ET, June 23,
2020 https://www.federalregister.gov/d/2020-08717
Comprehensive Care for
Joint Replacement Model 7CJR Proposed Rule Summary
• The rule proposes to change certain aspects of the CJR model
including:
– Episode of care definition
– Target price calculation
– Reconciliation process
– Beneficiary notification requirements
– Appeals process
– Gainsharing caps
– Medicare program rule waivers
• The rule proposes to extend the CJR model for an additional 3
years through December 31, 2023, to allow time to test the
proposed changes.
• The proposed rule also solicits comment on future bundled
payment models in the ASC setting.
Comprehensive Care for
Joint Replacement Model 8The CJR Model
• The Comprehensive Care for Joint Replacement (CJR)
model aims to support better and more efficient care for
beneficiaries undergoing a lower extremity joint
replacement (LEJR).
• The model allows CMS to continue gaining valuable
experience with episode payments for hospitals, and
their collaborating post-acute care and other providers,
with variety in utilization patterns and patient
populations.
Comprehensive Care for
Joint Replacement Model 9CJR Participants
• November 2015 Final Rule: Hospitals in 67 selected metropolitan statistical
areas (MSAs), with limited exceptions. The MSAs were randomly selected
from 294 eligible MSAs and presented in the final rule.
• December 2017 Final Rule: Rural and low-volume hospitals selected for
participation in the CJR model, as well as those hospitals located in 33 of the
67 MSAs, were given a one-time option to choose whether to continue their
participation in the model through December 31, 2020.
• February 2020 Proposed Rule: CMS proposes the model changes and
extension would apply only to those participant hospitals with a CMS
Certification Number (CCN) primary address in the 34 mandatory MSAs. The
model changes and extension would exclude participant hospitals in those
mandatory MSAs that are “low-volume hospitals” or that have received a
notification from CMS dated prior to October 4, 2020, that they have been
designated as “rural hospitals” (each as defined in 42 CFR 510.2)
Comprehensive Care for
Joint Replacement Model 10CJR Episode Definition
• Currently, CJR model episodes are initiated by an inpatient MS -DRG 469 or
470 discharge of an eligible Medicare beneficiary from a CJR participant
hospital.
o The proposed rule proposes to change this episode definition in order
to address the removal of Total Knee Arthroplasty (TKA) and Total Hip
Arthroplasty (THA) from the inpatient-only (IPO) list, which allows
these procedures to be reimbursed by Medicare when performed in
the outpatient (OP) setting.
o We are proposing that TKA and THA procedures performed in the OP
setting will trigger a CJR episode. OP TKA episodes will be reconciled
against the MS-DRG 470 without hip fracture target price, while OP
THA episodes will be reconciled against either the MS-DRG 470 with
hip fracture or without hip fracture target price, as applicable.
Comprehensive Care for
Joint Replacement Model 11CJR Payment and Pricing:
Target Price Calculation
• Currently, CJR target prices are based on 3 years of historical data.
• The proposed rule proposes to set target prices based on one year
(the most recently available year) of baseline claims data.
• Currently, based on 100% regional pricing
o The proposed rule does not propose to change the regional pricing
approach. However:
o The proposed rule proposes to remove the use of anchor factors and
weights.
o We seek comment on the appropriateness of moving to a national pricing
approach in future years of the CJR model.
Comprehensive Care for
Joint Replacement Model 12CJR Payment and Pricing:
Reconciliation
• The proposed rule proposes to add:
o Additional risk adjustment for the age bracket and HCC count applicable to
a beneficiary in a CJR episode; we will continue to use the presence or
absence of a hip fracture in setting the CJR target prices.
o A retrospective trend adjustment factor to better capture changes in
service delivery patterns in the target price.
• Currently, there are 2 reconciliation periods after each CJR performance year.
o The proposed rule proposes to shift to one reconciliation period that
would be conducted 6 months after the close of each performance year.
Comprehensive Care for
Joint Replacement Model 13CJR Payment and Pricing:
Linking Quality to Payment
• The Composite Quality Score (CQS) determines whether a participant is eligible for a reconciliation
payment (if savings are achieved beyond the quality-adjusted target price) and what effective discount
percentage is applied to the CJR-episode benchmark price for reconciliation payment.
o Currently, participants with unacceptable quality are not eligible for reconciliation payments and
have an effective discount percentage of 3%.
• The proposed rule does not propose to change this.
o Currently, those with acceptable, good, or excellent quality are eligible for reconciliation payment
and have an effective discount percentage of 3%, 2%, or 1.5%, respectively.
• The proposed rule proposes to move to a 0% quality withhold for participants with excellent
quality scores and a 1.5% withhold for good quality scores.
• CJR participants with a higher level of quality performance would generally experience a lower
effective discount percentage at reconciliation, resulting in greater financial opportunity for the CJR
participant.
Comprehensive Care for
Joint Replacement Model 14CJR Payment and Pricing:
High Cost Episode Cap
• We currently apply a cap at 2 standard deviations above the
regional mean (high episode payment ceiling) when calculating
initial CJR target prices and when comparing actual CJR episode
payments to CJR episode benchmark and quality adjusted target
prices at reconciliation.
o The proposed rule proposes to set the cap (high episode
payment ceiling) at the 99% percentile of arrayed actual
costs for each episode for each region (U.S. Census division).
Comprehensive Care for
Joint Replacement Model 15CJR Financial Arrangements:
Gainsharing Payments, Distribution Payments, and Downstream
Distribution Payments
• Consistent with applicable law and regulations, CJR participant hospitals
may engage in financial arrangements under the model.
• CJR participant hospitals may share reconciliation payments and internal
cost savings with collaborators.
• Collaborators may share gainsharing payments as distribution payments to
collaboration agents (physician group practice (PGP) members, non-
physician practitioner group practice (NPPGP) members, ACO participants,
or ACO providers/suppliers).
• Collaboration agents that are PGPs or NPPGPs apart of a collaborator ACO
may share distribution payments as downstream distribution payments to
downstream collaboration agents who are physician group practice
members or non-physician group practice members.
Comprehensive Care for
Joint Replacement Model 16CJR Financial Arrangements:
Elimination of 50 Percent Cap on Gainsharing Payments, Distribution
Payments, and Downstream Distribution Payments
• In regards to physicians or non-physician practitioners, the CJR
model has always included a cap on gainsharing payments,
distribution payments, and downstream distribution
payments.
• We are proposing to eliminate the 50% cap on Gainsharing
Payments, Distribution Payments, and Downstream
Distribution Payments. It was determined that the existing
cap:
o Is arbitrary and limiting
o Its burdens outweigh its benefits
o Is consistent with BPCI Advanced policy
Comprehensive Care for
Joint Replacement Model 17CJR Program Rule Waivers:
Skilled Nursing Facility (SNF)
• The CJR model waives the SNF 3-day rule for coverage of a SNF stay
following the anchor hospitalization beginning in performance year 2.
• Beneficiaries discharged pursuant to the waiver must be admitted to
SNFs rated 3-stars or higher on the CMS Nursing Home Compare
website.
• Beneficiaries must NOT be discharged prematurely to SNFs, and they
must be able to exercise their freedom of choice without patient
steering.
• We propose to extend the 3 day SNF waiver to include beneficiaries
who initiate CJR episodes in the outpatient setting.
Comprehensive Care for
Joint Replacement Model 18CJR Program Rule Waivers:
Direct Supervision Requirement
• The CJR model waives the direct supervision requirement to allow clinical
staff to furnish certain post-discharge home visits under the general,
rather than direct, supervision of a physician or nonphysician
practitioners.
• The waiver allows a CJR beneficiary who does not qualify for home health
benefits to receive a maximum of 9 post-discharge visits.
• We propose to extend the waiver of the direct supervision requirement
for certain post-discharge home visits to include beneficiaries who
initiate CJR episodes in the outpatient setting.
Comprehensive Care for
Joint Replacement Model 19CJR Beneficiary Protections:
Beneficiary Notification
• The participant hospital notification informs Medicare
beneficiaries of their inclusion in the CJR model and provides
a paper, detailed explanation of the model.
• We propose changes to the requirements for when the
participant hospital notification must be provided to
Medicare beneficiaries receiving a CJR anchor procedure,
whether inpatient or outpatient.
Comprehensive Care for
Joint Replacement Model 20Evaluation of the CJR model: Focus Areas
• The evaluation will assess the impact of the CJR model on the
aims of improved care quality and efficiency as well as reduced
health care costs.
• Focus areas include:
o Payment and utilization impact
o Quality of care and outcomes
o Unintended consequences
o Referral patterns and market impact
o Potential for extrapolation of results
Comprehensive Care for
Joint Replacement Model 21Comprehensive Care for
Joint Replacement Model
Policy and Regulatory Revisions in Response to the
COVID-19 Public Health Emergency
Interim Final Rule with Comment Period
Heather Holsey, JD, MS
Matthew Fox, MPP
Sarah Mioduski, JD
Center for Medicare & Medicaid Innovation
Centers for Medicare & Medicaid Services
22Interim Final Rule With Comment
Period (IFC) [1]
• On April 6, 2020, CMS published an Interim Final Rule
with Comment to make policy and regulatory revisions in
response to the COVID-19 public health emergency,
including programmatic changes to the CJR model
• These regulations are applicable beginning on March 1,
2020.
• Instructions for submitting comments can be found in the
proposed rule. To be assured consideration, comments
must be received no later than 5 p.m. on June 1, 2020.
Comprehensive Care for
Joint Replacement Model 23Interim Final Rule With Comment
Period (IFC) [2]
• 3-month extension to CJR performance year
(PY) 5
– CJR model will now end on March 31, 2021,
rather than ending on December 31, 2020
• Update to the extreme and uncontrollable
circumstances policy to account for episodes
impacted by the COVID-19 pandemic
Comprehensive Care for
Joint Replacement Model 24Interim Final Rule With Comment
Period (IFC) [3]
• Financial Safeguards
– For a fracture or non-fracture episode with a date of
admission to the anchor hospitalization that is on or
within 30 days before the date that the emergency
period begins (March 1, 2020) or that occurs through
the termination of the emergency period, actual
episode payments are capped at the target price
determined for that episode under § 510.300.
– Applies to all participant hospitals
Comprehensive Care for
Joint Replacement Model 25Comprehensive Care for
Joint Replacement Model
Inpatient Prospective Payment System (IPPS)
FY 2021
Heather Holsey, JD, MS
Matthew Fox, MPP
Sarah Mioduski, JD
Center for Medicare & Medicaid Innovation
Centers for Medicare & Medicaid Services
26Inpatient Prospective Payment System
(IPPS) FY 2021 Proposed Rule
• The Inpatient Prospective Payment System Fiscal Year 2021
Proposed Rule proposes to create two new MS-DRGs, MS-
DRG 521 (Hip Replacement with Principal Diagnosis of Hip
Fracture with MCC) and MS-DRG 522 (Hip Replacement with
Principal Diagnosis of Hip Fracture without MCC).
• CMS is seeking comment on the effect this proposal would
have on the CJR model and whether to incorporate MS-DRG
521 and MS-DRG 522, if finalized, into the CJR model’s
proposed extension rule.
• Instructions and deadline for submitting comments can be
found in the proposed rule.
Comprehensive Care for
Joint Replacement Model 27Comprehensive Care for
Joint Replacement Model
Public Comment Submission Instructions
Heather Holsey, JD, MS
Matthew Fox, MPP
Sarah Mioduski, JD
Center for Medicare & Medicaid Innovation
Centers for Medicare & Medicaid Services
28When and Where Do I Submit
Comments For CJR Expansion Rule?
• The CJR Model proposed rule includes proposed changes not reviewed in this
presentation. We will not consider feedback during this call as formal comments on
the rule.
o Reference the proposed rule for information on submitting these comments by
the close of the comment period, which has been extended to June 23, 2020.
When commenting, refer to file code CMS-5529-P.
• Instructions for submitting comments can be found in the proposed rule;
o *Note-FAX transmissions will not be accepted.
• You must officially submit your comments via:
o Regulations.gov (electronically)
o Regular mail
o Express or overnight mail
o Hand/courier
• For additional information on the CJR model, please visit
innovation.cms.gov/initiatives/cjr
Comprehensive Care for
Joint Replacement Model 29Comprehensive Care for
Joint Replacement Model
Announcements & Reminders
30CJR Connect Guidance
• All of the materials from this webinar are available on CJR Connect, in the CJR
Libraries
– If you don’t have a CJR Connect account, go to:
https://app.innovation.cms.gov/CJRConnect/CommunityLogin and click “New User? Click
Here”
• A recent change to CJR Connect means that users who have not been active for 60
days or more will have their accounts suspended.
– To avoid suspension, users must log in at least once every 60 days.
• If your CJR Connect account has been suspended and you want to regain access,
follow the instructions below:
– Email the CMMI Connect Help Desk at CMMIConnectHelpDesk@cms.hhs.gov or call 1-888-
734-6433 (select option #2) and provide your name, organization, and any associated model
identifiers (CCNs).
Comprehensive Care for
Joint Replacement Model 31Reminders
• Public comment period for the CJR Proposed Rule closes at 5:00 pm ET on June
23, 2020.
• Public comment period for the Interim Final Rule with Comment Period closes at
5:00 pm ET on June 1, 2020.
• Feedback from this event WILL NOT BE CONSIDERED as formal comments on the
aforementioned rules.
• Send any questions or CJR model points of contact updates to
CJRSupport@cms.hhs.gov.
• To request a CJR Connect account, go to:
https://app.innovation.cms.gov/CJRConnect/CommunityLogin and click “New
User? Click Here.”
• Please take a few minutes to respond to the Post-Event Survey.
Comprehensive Care for
Joint Replacement Model 32You can also read
