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.

The proposed rule for the CJR model was published on July 9, 2015, with the comment period ending September 8, 2015. After reviewing nearly 400 comments from the public on the proposed rule, several major changes were made from the proposed rule, including changing the model start date to April 1, 2016. The final rule was placed on display on November 16, 2015 and can be viewed at the Federal Register.

Final Rule and Interim Final Rule with Comment: Cancellation of Advancing Care Coordination through Episode Payment and Cardiac Rehabilitation (CR) Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement (CJR) Payment Model: Extreme and Uncontrollable Circumstances Policy for the CJR Payment Model

This final rule and interim final rule with comment cancels the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model and rescinds the regulations governing these models. It also finalizes revisions to certain aspects of the Comprehensive Care for Joint Replacement (CJR) model, including: giving certain hospitals selected for participation in the CJR model a one-time option to choose whether to continue their participation in the model; technical refinements and clarifications for certain payment, reconciliation and quality provisions; and a change to increase the pool of eligible clinicians that qualify as affiliated practitioners under the Advanced Alternative Payment Model (APM) track. Additionally, it finalized and seeks comment on an extreme and uncontrollable circumstances policy to provide flexibility in the determination of episode costs for CJR participant hospitals located in areas impacted by extreme and uncontrollable circumstances. The final rule is now available and a fact sheet summarizing the major changes in the rule is now available. Comments on the extreme and uncontrollable policy must be received at one of the addresses provided in the interim final rule no later than 11:59 p.m. EST on January 30, 2018.

Opt-In Period and instructions for eligible CJR participant hospitals: Note Opt-In Period is open from January 1, 2018 through 11:59 P.M. EST January 31, 2018

The December 1, 2017 final rule established that participation in the CJR model will automatically terminate for participant hospitals located in the 33 voluntary participation MSAs, low volume hospitals, and rural hospitals as of February 1, 2018 UNLESS these hospitals notify CMS of their election to continue their participation in the CJR model. The Opt-In Period will be open from January 1, 2018 until 11:59 p.m. EST on January 31, 2018. The Voluntary Participation Election Letter Template can be used by participant hospitals located in the 33 voluntary participation MSAs, low volume hospitals, and rural hospitals to submit this notification to CMS.

All CJR participant hospitals, their MSAs, MSA status (mandatory or voluntary), and low volume or rural status based on the December 1, 2017 final rule and interim final rule with comment is now available.

The Voluntary Participation Election Letter template is now available (PDF). Please note one completed  Voluntary Participation Election Letter must be submitted for EACH hospital that is choosing to opt-in to the CJR model. The Voluntary Participation Election Letters must be signed by the Administrator, Chief Financial Officer or Chief Executive Officer of the hospital. Please submit the completed Voluntary Participation Election Letter(s) to CJRSupport@cms.hhs.gov by 11:59 p.m. EST January 31, 2018. Please note that incomplete or inaccurate submissions will not be accepted and will be returned to the submitter for correction. Any corrections to the Voluntary Participation Election Letter that CMS requests must be addressed and correctly resubmitted by the deadline.

To elect continued participation in the model, CJR participant hospitals should:

  • Step 1: Confirm their status as eligible to voluntarily participate in the CJR model from the complete list of CJR hospitals and their status based on the December 1, 2017 final rule and interim final rule with comment (PDF)  |  (XLS)
  • Step 2: If eligible for and interested in voluntary participation, download and complete one Voluntary Participation Election Letter (using the CMS Voluntary Participation Election Letter template (PDF)) per CJR participant hospital
  • Step 3: Email the completed, unencrypted Voluntary Participation Election Letter to CJRSupport@cms.hhs.gov no later than 11:59 EDT on January 31, 2018

One completed Voluntary Participation Election Letter must be submitted for each hospital that is choosing to opt-in to the CJR model. The CJR Model Team will confirm receipt of submissions prior to issuing a formal notification of acceptance via email.

The CJR model team strongly recommends Voluntary Participation Election Letter submission in advance of the January 31, 2018 deadline to ensure that any corrections to incomplete or inaccurate submissions can be noted and corrected within the one time opt-in period. The CJR model team will be reaching out to all eligible CJR voluntary participants to ensure they are aware of the need to take action to elect continued participation in the CJR model if they would like to continue to participate.

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 will also use a simple risk stratification methodology to set different target prices for patients with hip fractures within each MS-DRG. 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.

In November, 2015 CMS posted a list of preliminary ICD-9-CM diagnosis codes to identify hip fracture cases in the historical period used to calculate 2016 target prices and requested public feedback on the list of codes. On December 16, 2015, CMS posted the list of ICD-9-CM diagnosis codes that will be used. In addition, CMS has posted a list of preliminary ICD-10-CM diagnosis codes (XLS) to indicate hip fracture and is seeking public feedback on the list of ICD-10-CM diagnosis codes by Friday, January 15, 2016.”

On July 25, 2016 the Department of Health & Human Services (HHS) proposed several changes to the model. These proposed changes would align the financial arrangements policies for CJR and the proposed EPMs; allow for ACOs, CAHs, and hospitals to be CJR collaborators; modify several terms and policies related to pricing and the reconciliation process; exclude a small number of beneficiaries aligned to certain ACOs from the CJR model; make small changes to our composite quality score methodology; and make the CJR model potentially eligible to be an Advanced APM. For additional information, a notice of proposed rule making is now available.

On December 20, 2016, CMS finalized the Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) rule. This final rule can be viewed at the Federal Register.

For more information on the EPMs and Cardiac Rehabilitation Incentive Payment Model, please visit the EPM web page.

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 are required to participate in the CJR model. As of November 16, 2015, approximately 800 hospitals are required to participate in the CJR model. Hospitals outside the selected geographic areas are not able to participate. There is no application process for this model.

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 rule also describes additional monitoring of claims data from participant hospitals to ensure that hospitals continue to provide all necessary services.

CMS is reaching out to hospitals in the selected MSAs with instructions on how to request data and other information regarding participation in the CJR model. If you are a hospital located in one of the MSAs selected for participation in the CJR model, please 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.

You can read the final rule on the Federal Register.

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 payment (XLS) (CSV) and those amounts are now available. 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