April 1 is almost here – and with it, CJR

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.

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

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.

Resources:

OrthoServiceline

Again, the complete  CMs rule