The Comprehensive Care for Joint Replacement (now known as CJR, no longer CCJR) program finalized last November by the Centers for Medicare and Medicaid Services will begin April 1 for hospitals in specified geographic areas. With this mandated orthopedic bundle program, CMS expects to save $153 by 2018.
The final rule, all several hundred pages of it, can be accessed here: http://innovation.cms.gov/initiatives/CJR/). But this quick “cheat sheet” adapted from articles written by Sheldon Hamburger, a principal of Raleigh, NC-based healthcare consulting group The Aristone Group, can help get you up to speed if your facility is affected.
It’s a mandated program. That means the program is mandatory for hospitals in 67 predetermined markets, called MSAs. There’s no application process – you’re in or you’re not, and if you’re in, you already know it.
- CJR is heavily based on the Bundled Payment for Care Improvement (BPCI) Model 2 program.
- Hospitals alone can be episode initiators – other entities such as group practices or skilled nursing facilities are excluded.
- The program begins April 1, 2016 and continues for 5 years – (this first “year” is only 9 months long – the remainder of 2016). You are at risk beginning Jan 1, 2017 (there is only upside during 2016).
- Gainsharing with other providers is allowed within program guidelines.
- Price targets become 100% regional-based by year 4 (phased in over time).
There’s more. Medicare takes 3% off the top of the total program. That means you need to drive total spend down by 3% to break even. If the post-acute portion is about 50% of the bundle, you need to drive post-acute spend down by 6% just to break even.
- CMS will grant these waivers:
- An “incident to” rule for home health allows post-discharge home visits where they were previously not allowed.
- Telehealth services are allowed in all geographies.
- SNF 3-day in years 2-5 of the program.
- A special ruling (see the CJR URL above) addresses safe harbor for issues such as anti-kickback, CMP, self-referral, etc.
- All providers will continue billing FFS meaning your revenue cycle model will not change.
- Gains/losses are calculated on a retrospective basis annually. Stop-loss and stop-gain limits protect you against big losses in exchange for limits on gains. CMS estimates that a small number of hospitals will be affected by the stop-loss and almost no hospitals will be affected by the stop-gains.
- You must meet specific quality performance measures to be eligible for the savings you generate. A score compared to national averages will determine your eligibility to share in savings as well as possible “Quality Incentive Payments.”
- Claims data is available on request. The process for requesting data has not yet been determined.
If you’re not in the program, you may want to consider preparing; it’s expected this program will be expanded in the future. Here are some hints:
- Get experienced help for your project. Do this early, as qualified help is in great demand. Consider including an analytics partner.
- Identify your surgeon partners. Begin negotiating contract terms; contracts must be in place by April 1, 2016 if surgeons are to share in gains for 2016.
- Establish a formal selection/integration process and associated performance criteria in order to maximize your revenue potential.
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This information is not intended to replace the advice of a doctor. Blue Sky disclaims any liability for the decisions you make based on this information.