Comprehensive Care for Joint Replacement (CJR) Model

Getting Ready For April 1st: What You Need to

Know

March 15, 2016

Agenda

• Upcoming CJR Webinars• Important CJR Model Dates• CJR Overview• CJR Model Requirements: How to Comply• How to Request and Receive Data• Resources for CJR Hospitals

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Upcoming CJR Webinars

Webinar Date & Time

Quality Measures and the Quality Composite Score

Thursday, March 17, 20163:00-4:00 p.m. Eastern Time

CJR Learning System Kickoff Wednesday, April 6, 201612:00-1:30 pm Eastern Time

Registration links for these events have been sent to primary points of contact at each CJR hospital. If you need the link, email cjrsupport@cms.hhs.gov.

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mailto:cjrsupport@cms.hhs.gov

CJR Overview- Dates

Important CJR Model Dates

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Important Dates

• The CJR model begins April 1, 2016• The model will consist of 5 performance years

− Performance Year 1: April 1, 2016 – December 31, 2016

• No downside risk during Year 1• Performance Year 1 reconciliation in spring

2017: quality and financial results

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CJR Overview

CJR Overview

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CJR Model: Description

• CJR is an episode-based payment model for lower extremity joint replacement (LEJR) procedures for Medicare fee-for-service beneficiaries

• CJR episodes include:− Hospitalization for LEJR procedure assigned MS-DRG 469 or 470 and

90 days post-discharge− All Part A and Part B services, with the exception of certain

excluded services that are clinically unrelated to the episode• The CJR model will be implemented in 67 metropolitan statistical areas

(MSAs)• Participant hospitals in these selected MSAs are all acute care

hospitals paid under the IPPS that are not currently participating in Model 1 or Models 2 or 4 of the Bundled Payments for Care Improvement (BPCI) initiative for LEJR episodes

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CJR Model: Financial

• Providers and suppliers continue to be paid via Medicare FFS

• Participant hospitals will receive prospective episode target prices that reflect expected spending for a LEJR episode. After a performance year,actual episode spending will be compared to the episode target prices

− If aggregate target prices are greater than actual episodespending, hospitals may receive a reconciliation payment, subject to quality performance

− If aggregate target prices are less than actual episodespending, hospitals will be responsible for making a paymentto Medicare

• Responsibility for repaying Medicare begins in Year 2, with no downside responsibility in Year 1

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CJR Model: Target Prices

• Target prices will be set for episodes anchored by MS-DRG 469 vs. MS-DRG 470 and for episodes with hip fractures vs. without hip fractures

• Based on 3 years of historical data• Includes 3% discount to serve as Medicare’s savings• Based on blend of hospital-specific and regional episode data (Census

Division), transitioning to regional pricingTarget Price Hospital-Specific and Regional Blend

Year Hospital-Specific Portion Regional Portion

Year 1 2/3 1/3

Year 2 2/3 1/3

Year 3 1/3 2/3

Year 4 blank 100%

Year 5 blank 100%9

Quality

• In the final rule, we finalized two quality measures:

1. Hospital Level Risk Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) measure (NQF #1550)

2. Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure (NQF #0166)

• In addition, we are encouraging voluntary submission of THA/TKA patient-reported outcomes (PRO) and limited risk variable data

• The next CJR 101 Webinar, “Quality Measure and the Composite Quality Score” will take place on Thursday, March 17th from 3:00-4:00pm EST

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Quality: Composite Quality Score

• Composite quality score links quality to payment

• Hospitals are assigned a composite quality score each year based on their performance and improvement on the two quality measures:

1. THA/TKA Complications measure (NQF #1550)

2. HCAHPS Survey measure (NQF #0166)

• Successful submission of THA/TKA PRO and limited risk variable data

− Performance and improvement on the PRO data elements are not taken into consideration as finalized in the rule

For more information regarding the composite quality score methodology, please refer to Section III.C.5.b.(5)(c) “Methodology to Link Quality and Payment” on page 73363 of the final rule

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Quality: Link to Payment

• Hospitals may experience different effective discount percentages at reconciliation due to quality adjustments

−Refer to Tables 19-21 on page 73378 of the final rule

• Hospitals with scores placing them in “Good” or “Excellent” quality categories will either

−Receive a higher reconciliation payment or

−Have less repayment responsibility

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Program Rule Waivers

• For CJR post-discharge home visits, CMS will waive the“incident to” direct physician supervision rule for physician services

• Allows clinical staff of a physician or non physician practitioner tofurnish a visit in the beneficiary’s home under the general supervision of a physician

• Permitted only for beneficiaries who do not qualify for Medicare coverage of home health services

• Allows a maximum of 9 visits during the episode• Services furnished under the waiver will be billed under the

MPFS by the physician, NPP, or by the entity, including a hospital, to which the supervising physician or NPP has reassigned his or her benefits

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Program Rule Waivers

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

• Telehealth visits under the waiver cannot be a substitute for in-person home health services paid under the home health prospective payment system

• Requires all telehealth services to be furnished in accordance with all other Medicare coverage and payment criteria except that payment for the special home health visits under the model will be paid at a special rate

• The facility fee paid by Medicare to an originating site for a telehealth service is waived if the service was originated in the beneficiary’s home

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Program Waivers: Skilled Nursing Facility

• CJR model waives the SNF 3-day rule for coverage of a SNF stayfollowing the anchor hospitalization beginning in year 2 on January 1, 2017. CJR hospitals may use the SNF 3-day stay waiver for episodes that begin on or after January 1, 2017.

• Beneficiaries discharged pursuant to the waiver must be transferred to SNFs rated 3-stars or higher for at least 7 of the previous 12 months on the CMS Nursing Home Comparewebsite. A list of qualifying SNFs will be posted to the CMS website prior to each calendar quarter to which it applies

• Beneficiaries must NOT be discharged prematurely to SNFs, andthey must be able to exercise their freedom of choice withoutpatient steering. Beneficiaries maintain the right to choose any provider or supplier

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Financial Arrangements

• Consistent with applicable law, participant hospitals may have certainfinancial arrangements with Collaborators to support their efforts toimprove quality and reduce costs

• CJR Collaborators may include the following provider and suppliertypes:− Skilled nursing facilities− Home health agencies− Long term care hospitals− Inpatient rehabilitation facilities− Physician Group Practices− Physicians, non-physician practitioners, and providers and suppliers

of outpatient therapy16

Financial Arrangements

• Participant hospitals will likely sign collaborator agreements throughout the duration of the CJR model, not only prior to April 1, 2016.– Section 510.500(b) of the CJR final rule specifies that “the parties must

enter into a sharing arrangement before care is furnished to CJR beneficiaries under the terms of the sharing arrangement.”

– The effect of this provision is that while a CJR collaborator could enter into a collaborator agreement on, for example, October 1, 2016, the calculation of any subsequent gainsharing payments pursuant to that agreement could not be inclusive of care furnished to CJR beneficiaries prior to October 1, 2016.

– CJR collaborators may only receive a gainsharing payment that includes dollars from a reconciliation payment or from internal cost savings that were generated during the period that the collaborator agreement with the CJR collaborator was in effect.

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CJR Model Requirements: How to Comply

CJR Model Requirements: How to Comply

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Compliance with the Requirements of Participation

• Participant hospitals, and any entity or individual furnishing a service to abeneficiary during a CJR episode, must comply with all requirements ofparticipation for the CJR model

• CMS may do one or more of the following if a participating hospital fails to complywith any of the requirements of the CJR model:

− Issue a warning letter to the participant hospital

− Require the participant hospital to develop a corrective action plan

− Reduce or remove a participant hospital's positive NPRA calculation

− Increase the repayment amount on the reconciliation report by 25 percent for the performance year in which the noncompliance occurred by the participant hospital

− In extremely serious circumstances, expulsion from the model and/or othersanctions including suspension of payments or revocation from the CJR modelif indicated 19

CJR Model Requirements

Compliance with CJR Final Rule• Beneficiary notification• Discharge planning• Required quality measures• Financial arrangements• CJR data• Medicare Program Rule Waivers• Payment

− A CJR hospital may earn a reconciliation payment or be required to repay Medicare for a portion of episode spending, beginning with the reconciliation for Performance Year 2

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Beneficiary Notification

• Beneficiary notification about the CJR model will support transparency.

− Providers and suppliers that are collaborators with a CJR hospitalare required to notify beneficiaries of the payment model

− If there are no collaboration arrangements, hospitals must notify the beneficiaries of the CJR model

− Beneficiary notification requirements focus the attention of all parties on the requirement to provide all medically necessary services

• CMS provided Beneficiary Notification Templates for hospitals, physicians, and PAC providers/suppliers

• Notifications should be distributed to beneficiaries in the timeframes outlined in the CJR final rule

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Beneficiary Notification

• CJR hospitals: At the time of the admission • Collaborators: When should the notification be sent out?

− Physicians: At the time the decision is made to pursue surgery

− PAC providers: Prior to the furnishing of the first service that is related to the joint replacement procedure

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Other Requirements

• CJR hospitals are required to provide a discharge planningnotice to beneficiaries

– Notice of any potential beneficiary financial liability• CJR hospitals are also required to inform beneficiaries of all

Medicare participating post-acute care providers in an area

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How to Request and Receive Data

How to Request and Receive Data

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Requesting and Receiving Data

• CMS will provide CJR hospitals with access to CJR episode data. In order to receive these data, CJR hospitals must request the baseline and quarterly data

• Email CJRSupport@cms.hhs.gov to receive the CJR Data Request and Attestation Form

• Once the form is received, CMS will provide instructions on accessing the data portal

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mailto:CJRSupport@cms.hhs.gov

Data Portal

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Available on the Portal Today

• What’s included:

− README file of CJR episode and target prices methodology (technical specifications in PDF format)

− Target prices for April-September 2016− Historical claims (includes enrollment, claim, and episode summary

information) *these files contain personally-identifiable information*− Historical claim summaries (statistics on episodes for your hospital and

region)− File layouts

• Target prices, historical claims, and historical claim summary files don’t have an extension. To open in Excel, rename the file to have .csv at the end. File layouts can be opened in Notepad or renamed to have a .txt at the end

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Resources for CJR Hospitals Title

Resources for CJR Hospitals

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Resources for CJR Hospitals

• CJR model final rule can be viewed at https://www.federalregister.gov

• CJR Connect website • CJR 101 webinar slides• Notification letter templates

• Model background documents, list of hospitals, other materials on the CMMI CJR public website at https://innovation.cms.gov/initiatives/cjr

• For CJR participant inquiries, email the CJR Support Team at cjrsupport@cms.hhs.gov

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https://www.federalregister.gov/https://innovation.cms.gov/initiatives/cjrmailto:cjrsupport@cms.hhs.gov

CJR Connect Overview

https://app.innovation.cms.gov/CJRConnect• Chatter: Ask questions, share information, manage your feed, bookmark

posts for later, and find people• Groups: Ask to join groups of interest to you and find “Active Groups” with

recent posts and activity• Libraries: Search resources using the content search, check out popular

tags, read document descriptions, and download useful documents• Events: Look at the schedule of upcoming Learning System events• If you need to reset password, email

CMMIConnectHelpDesk@cms.hhs.gov• To request access, email CJRSupport@cms.hhs.gov with your Name,

Position, Hospital Name, and CCN

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https://app.innovation.cms.gov/CJRConnectmailto:CMMIConnectHelpDesk@cms.hhs.govmailto:CJRSupport@cms.hhs.gov

2016 CJR Learning System Overview

Purpose: To support CJR hospitals’ success in the model and to facilitate peer-to-peer learning and exchange of ideas, successes, and promising practices.The Learning System will include:• Bimonthly newsletters• Monthly webinar events

– Action Groups– Affinity Groups– All-Participant Events– First CJR All-Participant Event: April 6, 2016 12-1:30 pm EDT

• CJR Connect Collaboration Site• Quarterly needs assessments

– First needs assessment open until March 18, 2016https://www.research.net/r/CJR_NA_Survey

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https://www.research.net/r/CJR_NA_Survey

Questions

Questions

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Comprehensive Care for �Joint Replacement (CJR) ModelAgendaUpcoming CJR WebinarsCJR Overview- DatesImportant DatesCJR OverviewCJR Model: DescriptionCJR Model: FinancialCJR Model: Target PricesQualityQuality: Composite Quality ScoreQuality: Link to PaymentProgram Rule WaiversProgram Rule WaiversProgram Waivers: �Skilled Nursing FacilityFinancial ArrangementsFinancial ArrangementsCJR Model Requirements: �How to ComplyCompliance with the Requirements of ParticipationCJR Model RequirementsBeneficiary NotificationBeneficiary NotificationOther RequirementsHow to Request and Receive DataRequesting and Receiving DataData PortalAvailable on the Portal TodayResources for CJR Hospitals TitleResources for CJR HospitalsCJR Connect Overview2016 CJR Learning System Overview Questions