The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that would make changes to the Comprehensive Care for Joint Replacement (CJR) Model and extend the demonstration for an additional three years through 2023. As of February 1, 2018, approximately 465 IPPS hospitals in 67 different MSAs are participating in the CJR model. Currently, there is no mandate for South Dakota PPS hospitals to participate but the proposed rule provides guidance if the rule were to include all PPS hospitals. The current CJR Model is scheduled to end on Dec. 31, 2020.
Among the proposed model changes, CMS would:
- Modify the episode-definition to include outpatient knee and hip replacements, addressing changes to the inpatient-only list that now allow for total knee and hip replacements to be treated in the outpatient setting;
- Change the basis of the target price from three years of claims data to the most recent one year of claims data;
- Move from two reconciliation periods to one conducted six months after the close of the performance year;
- Add additional episode-level risk adjustment based on the individual beneficiary’s age and hierarchical condition category count;
- Change the high episode spending cap calculation methodology used at reconciliation to add a retrospective trend adjustment factor;
- Update the quality discount factors applicable at reconciliation to participants with excellent and good quality scores to better recognize high-quality care;
- Make conforming changes to the beneficiary notification, gainsharing caps, appeals process, and waiver sections to align with the proposed model extension as well as the proposed changes to episode definition.
A fact sheet is available on the CMS website.