Comprehensive Care for Joint Replacement (CJR)
The Centers for Medicare & Medicaid’s (CMS) Comprehensive Care for Joint Replacement (CJR) model final ruling was released in November 2015 and the orthopaedic community is addressing the issues and figuring out how the ruling impacts them – especially when it comes to Clinical Data Registry participation. Utilizing the data from your participation with AJRR can be considered a quality initiative that can earn hospitals credit towards this CMS program.
What Exactly is the CJR?
The CJR is a five-year model with the goal of improving quality of care and cost efficiency in hip and knee procedures through bundled payments and quality measurement. It started on April 1, 2016, and is set to run through 2020. As of November 2015, about 800 hospitals in 67 geographical areas, or metropolitan statistical areas (MSAs), were required to participate. MSAs were selected because they are counties that have a central urban area that has a population of at least 50,000 people.
CJR participants receive target prices for their episodes of care from Medicare, and are paid under the usual payment system rules throughout the year. At the end of the CJR performance year, participants’ actual spending is compared to the target episode price, and based on their composite quality score and spending performance, Medicare will either provide additional payment to a hospital or request repayment.
How Can AJRR Help?
Although AJRR is unable to help hospitals with their target episode spending, the Registry can assist with CJR participants’ composite quality scores. The scores are determined by a hospital’s performance on a Total Hip Arthroplasty/Total Knee Arthroplasty Complications measure, a Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure, and submission of patient-reported outcomes and risk variable data. The composite quality score is out of 20 points, and participating hospitals receive their scores in the second quarter of each following performance year.
The Registry is able to collect PROs and limited risk variable data for CJR participants, and even has a “CJR template” that allows for easy submission to CMS. PROs and limited risk variables are currently only voluntary for CJR, but can provide participants with up to 2 points for their quality score, so they’re a great way to pad your score. As you can see in the chart below, the required PRO measures for CJR include the Veterans Rand 12 Item Health Survey (VR-12) or the Patient-reported Outcomes Measurement Information System (PROMIS) 10-Global, and the Hip disability and Osteoarthritis Outcome Score (HOOS), JR./Knee injury and Osteoarthritis Outcome Score (KOOS), JR. or their subscales.
The deadline for PRO submission in 2017 is October 31, 2017, and post-operative data on Performance Year 1 Patients and Pre-Operative Data on Performance Year 2 Patients are required. The minimum case requirement for successful PRO collection increases each year of the program; in Performance Year 2, the minimum is 60% of eligible procedures or at least 75 cases, whichever is lower. The chart below displays the minimum case requirements for subsequent performance years.
Have There Been Any Changes to the CJR Rule?
In December 2016, CMS finalized changes to the CJR rule, in addition to creating the Episode Payment Models (EPMs) and the Cardiac Rehabilitation (CR) Incentive Payment Model. The major takeaway from this CJR change is that the CJR is now considered an Advanced Alternative Payment Model (APM), giving clinicians more opportunities to qualify for a 5% incentive payment through the Medicare Access and CHIP Reauthorization Act (MACRA).
You may have heard about how in August 2017, CMS proposed to make additional changes to the CJR and cancel the mandatory EPMs and CR incentive payment model. This new rule would reduce the number of mandatory CJR participants from 67 to 34, and allow the 33 remaining MSAs to voluntarily participate. All low volume and rural hospitals in CJR MSAs would have voluntary participation as well. CMS is proposing a one-time participation election period for the voluntary MSAs and low volume and rural hospitals that would last from January 1, 2018 until January 31, 2018. Public comments for the rule are due on October 16, 2017.
If you are in one of the remaining MSAs or are planning to voluntarily participate in CJR, reach out to your region’s AJRR Program Coordinator if you are not already using our template to collect PROMs. We would be happy to help set you up so that you can qualify for the 2 quality points next year.
We've put together this Top 12 list of things to know about CJR and Clinical Data Registries.
Download the PRO and Risk Variable Data Elements list here.
More info about CJR can be found here
CMS-supplied Frequently Asked Questions can be found here