Comprehensive Care for Joint Replacement Model

The Comprehensive Care for Joint Replacement (CJR) model aims to support better and more efficient care for beneficiaries undergoing the most common inpatient surgeries for Medicare beneficiaries: hip and knee replacements (also called lower extremity joint replacements or LEJR). This model tests bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery. This model was implemented and modified through notice and comment rulemaking and the relevant proposed and final rules are linked at the bottom of this page. The model began on April 1, 2016 and will run through December 31, 2020. As of February 1, 2018 approximately 465 IPPS hospitals in 67 different MSAs are participating in this CJR model.

Background

Hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries and can require lengthy recovery and rehabilitation periods. In 2014, there were more than 400,000 procedures, costing more than $7 billion for the hospitalizations alone. Despite the high volume of these surgeries, quality and costs of care for these hip and knee replacement surgeries still vary greatly among providers.

For instance, the rate of complications like infections or implant failures after surgery can be more than three times higher at some facilities than others, increasing the chances that the patient may be readmitted to the hospital. And, the average Medicare expenditure for surgery, hospitalization, and recovery ranges from $16,500 to $33,000 across geographic areas.

Model design

The CJR model holds participant hospitals financially accountable for the quality and cost of a CJR episode of care and incentivizes increased coordination of care among hospitals, physicians, and post-acute care providers. The episode of care begins with an admission to a participant hospital of a beneficiary who is ultimately discharged under MS-DRG 469 (Major joint replacement or reattachment of lower extremity with major complications or comorbidities) or 470 (Major joint replacement or reattachment of lower extremity without major complications or comorbidities) and ends 90 days post-discharge in order to cover the complete period of recovery for beneficiaries. The episode includes all related items and services paid under Medicare Part A and Part B for all Medicare fee-for-service beneficiaries, with the exception of certain exclusions.

Every year during the approximate five performance years of this model, CJR hospitals will receive separate episode target prices for MS-DRGs 469 and 470, reflecting the differences in spending for episodes initiated by each MS-DRG. CMS uses a simple risk stratification methodology to set different target prices for patients with hip fractures within each MS-DRG and a list of the fracture codes that effect target price assignments is linked at the bottom of this webpage. This list is reviewed and updated by the CJR model team clinicians each year to ensure new fracture codes that are relevant to CJR episodes are incorporated. All providers and suppliers are paid under the usual payment system rules and procedures of the Medicare program for episode services throughout the year. At the end of a model performance year, actual spending for the episode (total expenditures for related services under Medicare Parts A and B) is compared to the Medicare target episode 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.

For the first 2 performance years of the model, participation in the CJR model was mandatory for all IPPS providers located within the 67 MSAs selected for the CJR model. CMS proposed and finalized several changes to the CJR model during the 2017 calendar year and in the final rule published on December 1, 2017, participation for all rural and low volume providers in CJR became voluntary as did participation for all providers located in 33 of the 67 MSAs. CMS held a one time opt-in election period during January of 2018 and providers who were eligible for voluntary participation were required to submit an opt-in election letter (using a CMS provided template) to CMS between January 1, 2018 and 11:59 p.m. on January 31, 2018. Of the approximately 323 providers eligible for voluntary participation, 86 providers opted to elect to continue to participate in CJR for the remaining performance years.

Other changes to the CJR model proposed and finalized in 2017 involved: modifying several terms and policies related to financial arrangements, pricing and the reconciliation process; excluding a small number of beneficiaries aligned to certain ACOs from the CJR model; making some technical refinements and clarifications for certain payment, reconciliation and quality provisions and making the CJR model eligible to be an Advanced APM.

Participants

CMS has implemented the CJR model in 67 geographic areas, defined by metropolitan statistical areas (MSAs). MSAs are counties associated with a core urban area that has a population of at least 50,000. Non-MSA counties (no urban core area or urban core area of less than 50,000 population) were not eligible for selection. The MSAs are listed below:



Except for those participating in Model 1, Models 2 or Model 4 of the Bundled Payments for Care Improvement (BPCI) initiative for LEJR episodes, hospitals paid under the Inpatient Prospective Payment System (IPPS) and located in the MSAs selected were required to participate in the CJR model for the first 2 performance years. For performance years 1 and 2 of the CJR model, approximately 800 hospitals were required to participate.  As of February 1, 2018, following the changes to the participation requirements established in the December 1, 2017 final rule, approximately 465 hospitals are participating in the CJR model for performance years 3 through 5. Hospitals outside the selected 67 geographic areas are unable to participate.

In the CJR model, beneficiaries retain their freedom of choice to choose services and providers. Physicians and hospitals are expected to continue to meet current standards required by the Medicare program. All existing safeguards to protect beneficiaries and patients remain in place. If a beneficiary believes that his or her care is adversely affected, he or she should call 1-800-MEDICARE or contact their state’s Quality Improvement Organization by going to http://www.qioprogram.org/contact-zones. The points of contact should be individuals employed by the hospital that would be the best people for CMS to reach out to with instructions for receiving data and other technical issues.

Prior to implementing this model on April 1, 2016, CMS reached out to hospitals in the selected MSAs with instructions on how to request data and other information regarding participation in the CJR model. Hospitals located in one of the MSAs selected for participation in the CJR model were asked to provide CMS with two points of contact for the CJR model by emailing cjr@cms.hhs.gov. Please include your hospital’s CCN in the subject line. The points of contact should be individuals employed by your hospital that would be the best people for CMS to reach out to with instructions for receiving data and other technical issues.

CMS and HHS Office of the Inspector General (OIG) will jointly issue waivers of certain fraud and abuse laws for purposes of testing this model. The waiver notice is available at the CMS Fraud and Abuse page.

Pricing

The episode benchmark prices used to calculate hospitals’ target prices are based on a blend of a hospital’s own historical standardized spending and regional historical standardized spending on LEJR episodes, moving towards 100% regional pricing for Performance Years 4 and 5. Regional historical standardized spending is also used to calculate the target price for any hospital with fewer than 20 LEJR episodes in the baseline period. The regional historical standardized payment amounts used to calculate target prices appear in the document below. They incorporate the 3% discount that we use to calculate prospective target prices, which may be further adjusted at reconciliation based on composite quality score.

Preliminary Performance Year 1 Reconciliation Payments

The list of CJR providers earning initial performance year 1 reconciliation payments (XLS) (CSV) and those amounts are available and linked at the bottom of this page. Providers earned initial performance year 1 reconciliation payments if they had actual episode spending below the target price and achieved a minimum composite quality score. Note that this provider list and/or the payment amounts are subject to change as the final reconciliation calculations for each performance year occur 14 months after the close of the performance year to allow for updated data, claims run out, adjustments for model overlaps, and other adjustments. This process was finalized through notice and comment rulemaking and the regulations are available at 42 CFR 510.305. No repayments to Medicare are required for performance year 1 as downside risk does not apply in the CJR model until performance year 2.

Questions regarding the Comprehensive Care for Joint Replacement Model can be directed to cjr@cms.hhs.gov.

Additional Information

Regulations & Notices

Fact Sheets

Participant Resources