Joint Replacement Model (CJR)

Jonathan Bennett, Senior Director, Decision SupportApril 5, 2016

1

Comprehensive Joint Replacement Program (CJR)• Program Overview

• Bundled Payments

• Data Models – DataGen

• Quality Reporting Requirements

2

CJR Overview• Start Date: April 1, 2016• Program Duration: 4 ¾ years• Frist Year: April 1, 2016 – December 31, 2016• MSAs: 67• MS-DRGs: 469 or 470

• Target prices will reflect the difference between elective procedures and those involving hip fractures

• Prices/payments: Includes IPPS operating & capital amounts

• Quality Performance: Composite quality score methodology

3

CJR Bundled PaymentsBundled Payments• Initial inpatient acute stay plus all covered services for

90 days post-discharge • Some exceptions for unrelated services/diagnoses • All providers continue to receive FFS payments • FFS payments are retrospectively reconciled to targets

Hospitals “Own the Bundles”• Excess of targets - risk• Below targets - reward• Quality metrics - must meet

4

CJR Target PricesSeparate Target Prices • MS-DRGs 469 and 470 with and without hip fractures• Based on three-years of historical data • Excludes payments/adjustments for IME, DSH, VBP,

Readmissions and HACs Discount Factor • Taken off the top to guarantee Medicare savings • Level of discount depends on quality performance score Blended Target • Transitions over time to 100% regional Rebasing • Baseline period will be updated every other year

5

CJR Estimated Performance Analysis

Case counts less than 11 are redacted per CMS data privacy rules6

Performance: DRG 470 without Hip Fracture

7

Performance: DRG 470 without Hip Fracture

8

DataGen Data Models • Review high-level reports

• Post acute care review

• Quality measures

• Drill-down reports are available from DataGen

9

CJR Quality Measures• Risk-standardized complication rate – NQF #1550• Patient experience surveys (HCAHPS) – NQF #0166• Patient reported outcome (PRO) data – functional

outcomes

10

CJR Quality Metric Analysis

11

CJR Quality Points Distribution

12

CJR Estimated Quality Metric Analysis

13

CJR Comparison Data: Quality Scores

14

CJR Quality Measures – PRO Measure• Patient reported outcome measure

• Patient’s perspective• Voluntary submission – “not really”

15

CJR Quality Measures – PRO MeasureThe data elements include:• 4 unique patient identifier(s) • 11 risk variables

Pre-operative data collection – must be completed between 90 to 0 days prior to the THA/TKA procedure.

Post-operative data collection – must be completed between 270 to 365 days after the THA/TKA procedure.

Data submission must occur within 60 days of the most recent performance period.

16

PRO Measure – Data Elements• Date of birth• Race and ethnicity• Date of admission• Date of THA/TKA

procedure• Medicare HIC Number• Body mass index

• PROMIS Global or VR-12• TKA - KOOS• THA - HOOS• Use of chronic narcotics

(≥90 days)• Total pain joint count• Quantified spinal pain• Health literacy

questionnaire

17

PRO Measure – Performance Periods• Model Year 2016

• Performance period: July 1, 2016 through August 31, 2016• Successful Requirements: Submit pre-operative data on

primary elective THA/TKA procedures for ≥50% of eligible procedures or a total of 50 procedures.

• Model Year 2017• Performance period: July 1, 2016 through August 31, 2016• Successful Requirements: Submit post-operative data on

primary elective THA/TKA procedures for ≥50% of eligible procedures or a total of 50 procedures.

18

PRO Measures – Data Collection• Who’s going to collect the data?

• Work flow• Patient coordination

• What method will the data be collected?• Internal• Vendor

• How will the data be reported?• Department coordination• CMS template

19

CJR Quality Data Timeline

20

Thank you

21

Additional ResourcesCMS contact information

• CJR questions can be emailed to cjr@cms.hhs.gov

CMS’ CJR website • https://innovation.cms.gov/initiatives/cjr

22