what is the purpose of cjr medicare payment model

The CJR Model is a Medicare Part A and B payment model that 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.

Full Answer

What is the CJR model for Medicare?

CJR model: Rule Summary The Centers for Medicare & Medicaid Services have implemented a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model

What does CJR stand for?

Comprehensive Care for Joint Replacement (CJR) Model Introduction to Comprehensive Care for Joint Replacement (CJR) Model Proposed Rule to Final Rule

What are bundled payments under the CJR model?

Under the CJR Model these participant hospitals receive retrospective bundled payments for episodes of care for lower extremity joint replacement or reattachment of a lower extremity (collectively referred to as LEJR).

Is access to care impacted by the CJR model?

access to care should not be impacted by the CJR model. • This is a payment model that changes the payment methodology for hospitals in select geographic areas. • Beneficiary deductibles and copayments will not change

How does CJR help?

How the CJR model helps—and protects—beneficiaries: Patients can benefit from their hospitals and other health care providers (e.g., physicians, home health agencies, and nursing facilities) working together more closely to coordinate their care. Coordination of care leads to better outcomes, a better experience, and fewer complications, ...

Is lower extremity joint replacement a Medicare inpatient surgery?

Lower extremity joint replacements are the most commonly performed Medicare inpatient surgery, and utilization is predicted to continue to grow. These surgeries can require long recoveries that may include extensive rehabilitation or other post-acute care, which provides many opportunities to reward providers that improve patient outcomes.

What is CJR model?

The CJR Model is a CMS Center for Medicare and Medicaid Innovation (Innovation Center) model that aims to reduce Medicare expenditures while preserving or enhancing quality of care for Medicare beneficiaries. The Model tests whether 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. Under the CJR Model these participant hospitals receive retrospective bundled payments for episodes of care for lower extremity joint replacement or reattachment of a lower extremity (collectively referred to as LEJR). Currently, a CJR episode begins with an inpatient admission for 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 includes, with limited exception all care for 90 days following discharge.

How long is the CJR model?

Additionally, to allow time to evaluate the proposed changes, the rule proposes to extend the length of the CJR Model for an additional three years, through December 31, 2023, for certain participant hospitals.

How many years does the CJR model last?

The proposed rule proposes several changes to the CJR Model. Most notably, it proposes to extend the CJR Model for an additional 3 performance years, performance year 6 (2021) through performance year 8 (2023).

When did the CMS issue the rule?

Demonstration projects. Innovation models. Policy. On February 20, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule in the Federal Register ( https://www.federalregister.gov/public-inspection/current) which proposes a three-year extension and changes to the episode definition and pricing in ...

What is CCJR in Medicare?

The Centers for Medicare & Medicaid Services have implemented a new Medicare Part A and B payment model under section 1115A of the Social Security Act, called the Comprehensive Care for Joint Replacement (CJR) model (formerly using the acronym CCJR), in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for lower extremity joint replacement or reattachment of a lower extremity (LEJR).

Does CJR require a site?

CJR model waives the geographic site requirement for any service on the Medicare-approved telehealth list and the originating site requirement only to permit telehealth visits to originate in the beneficiary’s home or place of residence

What is CJR in Medicare?

On November 16, 2015, the Centers for Medicare and Medicaid Services (CMS) announced the final rule for the Bundled Payments for Care Improvement Initiative and the mandatory bundled payment test called Comprehensive Care for Joint Replacement known as CJR. Effective April 1, 2016, acute-care hospitals in 67 geographic regions (known as metropolitan statistical areas [MSAs]) around the country will automatically be part of this new program. The program goes for five years (although the first year is nine months long) with various terms and risks phased in over time. There is no application process and no “opt-out.”

Why does CMS provide waivers?

CMS provides a number of waivers under the CJR program to allow hospitals flexibility to experiment on methods to improve care and lower total spend. The three key waivers for care delivery are:

Is CJR a game changer?

Clearly, CJR is a game changer. With responsibilities now extending beyond discharge, hospitals need to become immediate experts in the post-acute care process. Using that newly acquired knowledge, the challenge will be to reengineer care delivery to optimize outcomes resulting in reduced spend.

Is CJR success dependent on data?

Like all valued-based programs, CJR success is heavily dependent on the availability and use of data. Your organization has plenty of data that will be helpful and should be used. CMS will provide data sets that will be essential for you to have, analyze and leverage to design and monitor your program.

What is CJR model?

The CJR model is designed to provide financial incentives to improve coordination of care for beneficiaries that we expect to lead to avoidance of post-surgical complications and hospital readmissions, as well as to improve patient experience through care redesign and coordination. Furthermore, we acknowledge that achievement of savings while ensuring high-quality care for Medicare FFS beneficiaries in LEJR episodes would require close collaboration among hospitals, Start Printed Page 73359 physicians, PAC providers, and other providers and suppliers. In order to encourage care collaboration among multiple providers of patients undergoing THA and TKA, we proposed three measures, as described in detail in section III.D.2. of this final rule, to determine hospital quality of care and to determine eligibility for a reconciliation payment under the CJR model. The measures we proposed are as follows:

When did Medicare sequestration come into effect?

In addition to the various incentive, enhanced and add on payments, sequestration came into effect for Medicare payments for discharges on or after April 1, 2013, per the Budget Control Act of 2011 and delayed by the American Taxpayer Relief Act of 2012.

What is IRF services update factor?

The proposed IRF services update factor applies to payments for services included in the episode paid under the Medicare inpatient rehabilitation facility prospective payment system (IRF PPS). We proposed to use changes in the IRF Standard Payment Conversion Factor, an input for the IRF PPS and defined in the IRF PPS Final Rule for the relevant years, to update Medicare payments for IRF services provided in the episode. The IRF Standard Payment Conversion Factor is the same for all IRFs and IRF services, so there is no need to account for any hospital-specific or region-specific IRF utilization patterns; each participant hospital and region would use the same IRF services update factor.

What is the SNF update factor?

The proposed SNF services update factor would apply to payments for services included in the episode and paid under the SNF PPS, including payments for SNF swing bed services. The update factor applied to the SNF services component of each participant hospital and region's historical average episode payments would be based on how average Resource Utilization Group (RUG-IV) Case-Mix Adjusted Federal Rates for the Medicare SNF PPS (defined in the SNF PPS Final Rule) have changed between the latest year used in the historical 3 years of episodes and the upcoming performance period under CJR. The average RUG-IV Case-Mix Adjusted Federal Rates would be specific to each participant hospital and region to account for hospital and region-specific SNF service utilization patterns. Hospital-specific and region-specific average RUG-IV Case-Mix Adjusted Federal Rates would be calculated by averaging the RUG-IV Case-Mix Adjusted Federal Rates for all SNF services included in the historical episodes attributed to each participant hospital and attributed to CJR eligible hospitals in the region, respectively. We note that the RUG-IV Case-Mix Adjusted Federal Rate may vary for the same RUG, depending on whether the SNF was categorized as urban or rural.

APMs

Meet the statutory definition of an APM. MIPS eligible clinicians participating in an APM are also subject to MIPS.

MIPS APMs

MIPS APMs have MIPS eligible clinicians participating in the APM on their CMS-approved participation list.

Advanced APMs

An Advanced APM is a track of the Quality Payment Program that offers a 5 percent incentive for achieving threshold levels of payments or patients through Advanced APMs. If you achieve these thresholds, you are excluded from the MIPS reporting requirements and payment adjustment.

Advanced & MIPS APMs

Most Advanced APMs are also MIPS APMs. MIPS Eligible clinicians participating in Advanced APMs are included in MIPS if they do not meet the threshold for payments or patients sufficient to become a Qualifying APM Participant (QP). The MIPS eligible clinician will be scored under MIPS according to the APM scoring standard.

Prepare to Participate

If you are interested in preparing to participate in an APM, you can receive further support with our technical assistance resources.

How to Contact The Cjr Model Team

• If you have questions regarding the Model, you can contact the CJR model team by emailing [email protected].

See more on innovation.cms.gov

Additional Information

Relevant Material

Fact Sheets

Participant Resources

Evaluation Reports