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  • Washington Highlights

    CMS Releases Comprehensive Care for Joint Replacement Payment Final Rule

    Len Marquez, Senior Director, Government Relations

    The Centers for Medicare and Medicaid Services (CMS) Nov. 16 released the final rule on the Comprehensive Care for Joint Replacement Payment (CJR) Model, which would mandate participation in a lower extremity joint replacement (LEJR) bundled payment program for certain acute care hospitals beginning April 1, 2016. The CJR program will run for five years through the end of 2020. However, participating hospitals will not face downside risk until January 2017.

    CMS made a number of notable changes in the final rule, including delaying the start date of the program by three months from Jan. 1, 2016, to April 1, 2016. The agency also changed their criteria regarding which metropolitan statistical areas (MSAs) would be included in the model, which ultimately lowered the number of participating MSAs from 75 to 67. Finally, CMS revised their target methodology to risk stratify the target price for each MS-DRG-anchored episode based on a beneficiary’s hip fracture status.

    The agency finalized its proposal to base target prices on a blend of regional and hospital-specific data for the first three years of the program. For years four and five, target prices will be completely based on regional pricing. CMS also noted that future regulations pertaining to fraud and abuse waivers will be issued by the Office of the Inspector General.

    Regarding the quality related changes in the final rule, CMS chose to incorporate an alternative methodology that utilizes an overall quality composite score to assess hospitals in the program. CMS originally proposed that hospitals would need to meet or exceed the 30th percentile performance threshold on three measures in order to qualify for savings.

    The new methodology, which places hospitals into one of four categories, allows for a greater spectrum of bonuses or penalties depending on performance. Hospitals will be assessed on the total hip arthroplasty/total knee arthroplasty (THA/TKA) complications measure, the Hospital Consumer Assessment of Healthcare Provider Systems (HCAHPS) survey, and on a patient reported outcomes (PRO) measure. The THA/TKA Readmissions measure was not finalized.