skip to Main Content

Required Comprehensive Care for Joint Replacement Payment Model

Written by: Darlene D'Altorio-Jones (1959-2015) on Tuesday, July 21, 2015 Posted in: Acute Care Rehab

CMS reported that in 2013 there were more than 400,000 lower extremity joint replacements procedures paid by Medicare. Costs exceeded $7 billion for hospitalization alone for those procedures. In addition, CMS states the quality and cost of care for hip and knee replacement surgeries still vary greatly among providers in relation to outcomes and overall costs.

To study this more fully, Congress provided the Secretary of Health and Human Services (HHS) with the authority to expand the scope and duration of a model being tested through rulemaking, including the option of testing on a nationwide basis through the CMS Innovation Center. The Comprehensive Care Joint Replacement (CCJR) Model is one of the models in proposed rule status. A pre-selected 75 Metropolitan Statistical Areas (MSA) and the facilities in those areas are already “signed up.”

Perhaps you have answered the call to be an Accountable Care Organization (ACO) or are one of the many who signed up to test Bundled Payment for Care Improvement (BPCI) through the CMS Center for Innovation. That’s all good; you raised your hand, submitted your proposal(s) and took on that challenge. For those of you who didn’t raise your hands, be alerted—CMS has released a proposed rule for the CCJR model of payment for Lower Extremity Joint Replacement (LEJR), and you could be in one of the 75 MSA’s that will be part of this payment model for up to 5 years for episodes of 90 days of care post discharge from the “anchor” hospitalization. If your MSA is selected, your participation in this model will be required and not voluntary. The proposed rule is out, and you have until September 8th, 2015 to weigh in. Find out if your facility is automatically enrolled. The start date is January 1, 2016, which is just around the corner.

The CCJR Model holds participant-enlisted hospitals financially accountable for the quality and cost of a lower extremity joint replacement episode of care (presently defined as 90 days following discharge from an Inpatient Prospective Payment System (IPPS) hospital) and would include all A & B payable services related to the joint replacement procedure. This payment model would incorporate traditional Medicare beneficiaries paid as IPPS in the acute care facility. The diagnosis-related groups (DRG) involved are MS-DRG 469 or 470.

CMS states, “All providers and suppliers would be paid under the usual payment system rules and procedures of the Medicare program for episode services throughout the year. This would include any partner facilities providing post -acute care services within that time frame. Following the end of a model performance year, actual spending for the episode (total expenditures for related services under Medicare Parts A and B) would be compared to the Medicare episode target price for the responsible hospital. Depending on the participant hospital’s quality and episode spending performance, the hospital may receive an additional payment from Medicare or be required to repay Medicare for a portion of the episode spending.”

There is no application process for participating in this model. The MSAs have been pre-selected with the rationale available in the proposed rule.

If you are in one of those statistical areas but are already participating in a Model 1 or Phase II of Model 2 or 4 of the BPCI initiative for lower extremity joint replacement episodes, you are exempt from this required model.

Facilities are encouraged to partner specifically with entities that can improve the overall patient outcome and reduce the overall costs of care. Disclosures to patients regarding those relationship expectations are outlined in the rule. Recall that on reconciliation, these costs will fit into or exceed target costs so that the benefits of services and outcomes must be highly weighed.

Patient quality data will be collected and beneficiaries will receive additional joint replacement surveys on experience of care. They will also receive additional control group surveys relating to the same experience outcomes.

It would benefit all those involved in the process to review the federal register proposed rule and to assess how these new expectations will impact your body of work. Since a proposed rule is generally carried forward to a final rule after all comments and recommendations are made, it only benefits participants to fully understand how this payment model will impact what may be a rather hefty portion of their annual income and workflow processes.

Don’t delay! Understand this payment model as it is coming to either your MSA or one near you. You won’t want to miss your opportunity to comment during the final rollout of this payment model reform.