Comprehensive Care for Joint Replacement
The Comprehensive Care for Joint Replacement (CJR) is a Part A and B bundled payment model authorized under the Affordable Care Act (ACA) and implemented under section 1115A of the Social Security Act. Regulations regarding the CJR were finalized in November, 2015 by the Centers for Medicare & Medicaid Services (CMS), and the first performance year of this 5 year program began on April 1, 2016. Acute care hospitals in 67 metropolitan statistical areas (MSAs), are mandated to participate in this episodic value-based health care program, which applies to Medicare fee-for-service beneficiaries who undergo lower extremity joint replacement or reattachment of a lower extremity (LEJR) procedures. The Montgomery, AL MSA is among those chosen for the program, and Rehab Select is participating in its post-acute network.
The CJR is a retrospective bundled payment model that was designed around the following goals: Improving efficiency and quality of care for Medicare beneficiaries who undergo LEJR procedures and encouraging hospitals, physicians and post-acute care providers to work together to improve coordination of care throughout the episode of treatment related to these procedures.
CJR episodes are triggered by the admission of eligible Medicare fee-for-service beneficiaries to a hospital paid under the Inpatient Prospective Payment System (IPPS) that results in a discharge paid under MS-DRG 469 (major joint replacement or reattachment of a lower extremity with major complications or comorbidities) or 470 (Major joint replacement or reattachment of lower extremity without major complications or comorbidities). The episode of care, as defined by CJR regulations, encompasses a period that begins three days before surgery and extends for 90 days after hospital discharge, and all care related to the LEJR procedure that is covered by Parts A and B and provided during that period is included in that episode.
CJR hospitals will be given separate episode target prices for each MS-DRG each year, and a specific pricing methodology for hip fractures within each MS-DRG has been implemented to reflect the higher spending associated with these cases. Throughout the year, all providers and suppliers will be paid under the usual Medicare payment rules and procedures for episode services. At the end of the year, actual spending for each episode will be compared to the Medicare target price for participating hospitals. CJR hospitals that keep expenses for these episodes below the target price will be eligible for reconciliation payments at year end, while those that exceed the target price may be required to repay a portion of the overrun.
Payment under the CJR program is also linked to quality measures. Participating hospitals will be given a composite quality score reflecting performance and improvement. These scores will be based on measuring factors such as complication rates, patient experience surveys and patient-reported outcomes, among others, and will be used to determine the amount of quality incentive payments hospitals will receive at year-end.
The bottom line of all of this is that the CJR model holds participating hospitals financially accountable for the quality and cost of a CJR episode of care, and since those episodes extend 90 days beyond hospital discharge, so too does that accountability. That means that coordination of care between hospitals and the physicians, post-acute care providers and other medical professionals they work with in LEJR cases is more important than ever before with the implementation of the CJR model. With that imperative in mind, Rehab Select has redesigned its care process to facilitate the seamless coordination and follow-up these cases require, ensuring that we -- and our care partners -- are well-prepared to embrace the new world of value-based healthcare heralded by bundled payment initiatives like the CJR.