March 2020 ~

In February, CMS’ Center for Medicare and Medicaid Innovation proposed a three-year extension for the Comprehensive Care for Joint Replacement (CJR) Model. The proposed rule seeks to modify the definition of an episode to include outpatient hip and knee replacements as well as calculation modifications for the basis for the target price.

The CJR Model is currently scheduled to end on December 31, 2020. In its proposal, CMS suggests extending the model for an additional three performance years, performance year 6 (2021) through performance year 8 (2023).

Additionally, the agency is also recommending changes be made to the definition of a CJR ‘episode’ so that it includes outpatient knee and hip replacements.  CMS says it is proposing this episode definition change to address changes to the inpatient-only (IPO) list that now allow for total knee and total hip replacements to be treated in the outpatient setting.

CMS is also proposing changes to change the basis for the CJR target price calculation from three years of claims data to the most recent one year of claims data, to remove the national update factor and twice-yearly update to the target prices that accounts for prospective payment system and fee schedule updates, to remove anchor factors and weights, to incorporate additional risk adjustment to the target pricing and to change the high episode spending cap calculation methodology.

In the proposal, CMS also recommends several changes to the CJR reconciliation process. Specifically, according to the fact sheet, the proposed rule has proposed to move from two reconciliation periods (conducted 2 and 14 months after the close of each performance year) to one reconciliation period that would be conducted 6 months after the close of each performance year, to add an additional episode-level risk adjustment beyond fracture status such that target prices will be further adjusted at the episode level based on the individual beneficiary’s age and HCC condition count. The agency is also proposing to change the high episode spending cap calculation methodology used at reconciliation, to add a retrospective trend adjustment factor that will better capture changes in Medicare program payment updates and care delivery patterns, and to change the quality (effective or applicable) discount factors applicable at reconciliation to participants with excellent and good quality scores to better recognize high-quality care.

To view the full text of the February 2020 CJR proposed rule, visit the Federal Register, and for more information on the CJR Model, visit the CMS Innovation Center.

 

Source(s): CMS Fact Sheet; HealthcareDIVE; Modern Healthcare; RevCycle Intelligence; Fierce Healthcare; Advisory Board; Healthcare Finance News;