Hip and knee replacement are the most common surgeries for Medicare beneficiaries and by providing participating hospitals with bundled payments for these procedures, as well as ankle replacements, the CJR Model encourages hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization or outpatient procedure through recovery.
Full Answer
What is comprehensive care for Joint Replacement (CJR)?
Nov 16, 2015 · Reasons for the CJR Model: Lower extremity joint replacements are the most commonly performed Medicare inpatient surgery, and utilization is predicted to continue to grow. These surgeries can require long recoveries that may include extensive rehabilitation or other post-acute care, which provides many opportunities to reward providers that improve patient …
What is the CJR model?
4/17/2017 1 CJR: Comprehensive Care for Joint Replacement Arnie Cisneros, PT Arnie Cisneros 30+ year Post-Acute Provider (Hosp, SNF, HH) 30+ year Home Health rehab clinician Home Health Strategic Management (2004) Hospital-2-Home Strategic Management (2014) Pioneer ACO (x3) –Post –Acute Strategist Model 2 BPCI Award –DMC –DRG 469/470
What happened to CJR in 2017?
Provider and Technical Fact Sheet for Performance Years 6-8. On November 16, 2015, the Centers for Medicare & Medicaid Services (CMS) finalized regulations implementing the Comprehensive Care for Joint Replacement (CJR) model to further our goals of improving the efficiency and quality of care for Medicare beneficiaries and to encourage hospitals, physicians, and post- …
What is the CJR final rule for Medicare?
The Comprehensive Care Joint Replacement Model (CJR) is a Medicare alternative payment model focused on elective hip and knee joint replacement patients. The model began April 1, 2016, and will run for 5 years. CJR was the first mandatory alternative payment model under Medicare—it required all acute
How does CJR work?
How does the CJR model work? A CJR 'episode' begins when a patient is admitted to a participating hospital and is ultimately discharged under either MS-DRG 469 (major joint replacement or reattachment of lower extremity with major complications or comorbidities) or MS-DRG 470 and ends 90 days post-discharge.
What is an episode of care under the CJR How long does it last?
For all episodes, the episode of care continues for 90 days following discharge from the inpatient hospitalization or the date of the outpatient procedure. With few exceptions, the episode includes all related items and services paid under Medicare Part A and Part B for eligible CJR patients.
What is a CJR scorecard?
The CJR Composite Quality Score is a score between 0 and 20 and is made up of 3 parts: Hip/Knee Complications – this risk-standardized complication rate is already published on the CMS Hospital Compare website.Jun 15, 2017
When does CJR end?
December 31, 2024The CJR model was extended through December 31, 2024. It would have expired on September 30, 2021. The extension only applies to hospitals located in the 34 metropolitan statistical areas (MSAs) selected by CMS in 2018.May 3, 2021
Which is the most common inpatient surgery for Medicare beneficiaries?
According to CMS, LEJR are the most common inpatient surgeries performed on Medicare beneficiaries and represent a substantial cost.May 5, 2021
What is the comprehensive care for joint replacement model?
Importance The Comprehensive Care for Joint Replacement (CJR) model is Medicare's mandatory bundled payment reform to improve quality and spending for beneficiaries who need total hip replacement (THR) or total knee replacement (TKR), yet it does not account for sociodemographic risk factors such as race/ethnicity and ...May 28, 2021
What does CJR stand for?
CJRAcronymDefinitionCJRCare for Joint Replacement (healthcare)CJRCour de Justice de la République (French: Court of Justice of the Republic)CJRCecil John Rhodes (British Prime Minister of the Cape Colony)CJRCentre for Japanese Research (University of British Columbia; Canada)7 more rows
What is bundled payment in healthcare?
A payment structure in which different health care providers who are treating you for the same or related conditions are paid an overall sum for taking care of your condition rather than being paid for each individual treatment, test, or procedure.
What is Bpcia?
Congress enacted the Biologics Price Competition and Innovation Act (BPCIA) to provide an abbreviated pathway for biosimilars to gain FDA approval through submission of an abbreviated Biologics License Application (aBLA).
How does CJR work?
How the CJR model helps—and protects—beneficiaries: 1 Patients can benefit from their hospitals and other health care providers (e.g., physicians, home health agencies, and nursing facilities) working together more closely to coordinate their care. Coordination of care leads to better outcomes, a better experience, and fewer complications, such as preventable readmissions, infections, or prolonged rehabilitation and recovery. 2 Beneficiaries will benefit from protections including: additional monitoring of claims data from participant hospitals to ensure that hospitals continue to provide all necessary services; continued protection of patient data under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other applicable privacy laws; and patient notification by providers and suppliers. Further, all existing safeguards to protect beneficiaries and patients will remain in place. If a beneficiary believes that his or her care has been adversely affected, he or she can call 1-800-MEDICARE or contact his or her state’s Quality Improvement Organization (QIO) by going to http://www.qioprogram.org/contact-zones. If concerns are identified, CMS will initiate audits and corrective action under existing authority. 3 Patients can continue to choose their doctor, hospital, skilled nursing facility, home health agency, and other provider, but now with the CJR model, their providers have incentives to better coordinate their care. From surgery to recovery, patients can receive more comprehensive, coordinated care from their providers focusing on the most appropriate options for their recovery and rehabilitative care.
Is lower extremity joint replacement a Medicare inpatient surgery?
Lower extremity joint replacements are the most commonly performed Medicare inpatient surgery, and utilization is predicted to continue to grow. These surgeries can require long recoveries that may include extensive rehabilitation or other post-acute care, which provides many opportunities to reward providers that improve patient outcomes.
What is ACO in healthcare?
An ACO is a healthcare organization characterized by a payment and care delivery model that seeks to tie provider reimbursementsto quality metrics and reductions in the total cost of care for an assigned population of patients.
What is the Silo effect?
The Silo effect refers to the lack of communication and support often found in acute care episodes. Provider types focus primarily on their own goals, often ignoring the needs of others.
What is CJR in Medicare?
A CJR episode is defined by the admission of an eligible Medicare fee-for-service beneficiary to a hospital paid under the Inpatient Prospective Payment System (IPPS) that eventually results in a discharge paid under MS-DRG 469 (Major joint replacement or reattachment of lower extremity with major complications or comorbidities) or 470 (Major joint replacement or reattachment of lower extremity without major complications or comorbidities).
How does CJR improve quality?
First, the model adopts a quality first principle where hospitals must achieve a minimum level of episode quality before receiving reconciliation payments when episode spending is below the target price. Second, higher episode quality, considering both performance and improvement, may lead a hospital to receive a higher reconciliation payment or have less repayment responsibility at reconciliation based on the hospital’s composite quality score, a summary score reflecting hospital performance and improvement on the following two measures:
What is an episode of care?
The episode of care begins with an admission to a participant hospital of a beneficiary who is ultimately discharged under MS-DRG 469 or 470 and ends 90 days post-discharge in order to cover the complete period of recovery for beneficiaries. The episode includes all related items and services paid under Medicare Part A and Part B for all Medicare fee-for-service beneficiaries, with the exception of certain exclusions. The following categories of items and services are included in the episodes: physicians' services; inpatient hospital services (including hospital readmissions); inpatient psychiatric facility (IPF) services; long-term care hospital (LTCH) services; inpatient rehabilitation facility (IRF) services; skilled nursing facility (SNF) services; home health agency (HHA) services; hospital outpatient services; outpatient therapy services; clinical laboratory services; durable medical equipment (DME); Part B drugs; hospice; and some per beneficiary per month (PBPM) care management payments under models tested under section 1115A of the Social Security Act. Unrelated services are excluded from the episode. Unrelated services are for acute clinical conditions not arising from existing episode-related chronic clinical conditions or complications of LEJR surgery; and chronic conditions that are generally not affected by the LEJR procedure or post-surgical care. The complete list of exclusions can be found on our website at https://innovation.cms.gov/initiatives/cjr, accompanied by the list of excluded MS-DRGs and ICD-10-CM diagnosis codes.
What is CJR model?
The CJR model is a retrospective bundled payment model. CMS provides participant hospitals with Medicare episode prices, called the target prices, prior to the start of each performance year. Target prices for episodes anchored by MS-DRG 469 vs. MS-DRG 470 and for episodes with hip fractures vs. without hip fractures are provided to participant hospitals each year. The target price generally includes a discount over expected episode spending and incorporates a blend of historical hospital-specific spending and regional spending for LEJR episodes, with the regional component of the blend increasing over time. All providers and suppliers furnishing LEJR episodes of care to beneficiaries throughout the year are paid under existing Medicare payment systems.
What is the CJR final rule?
As stated in the CJR final rule, each participant hospital must provide written notice to any Medicare beneficiary that meets the criteria in § 510.205 of his or her inclusion in the CJR model. The participant hospital and any CJR collaborator must provide the CJR beneficiary with notification. Physicians and hospitals are expected to continue to meet current standards required by the Medicare program. All existing safeguards to protect beneficiaries and patients remain in place. If a beneficiary believes that his or her care is adversely affected, he or she should call 1-800- MEDICARE or contact their state’s Quality Improvement Organization. CMS will also conduct additional monitoring of claims data from participant hospitals to ensure that hospitals continue to provide all necessary services.
What is track 1 in CJR?
Track 1 of the CJR model is an Advanced APM and the participation of eligible clinicians in track 1 will be considered in the determination of eligibility for an APM incentive payment. Track 2 of this model is an APM, but does not meet the Advanced APM criteria in the Quality Payment Program. To be an Advanced APM, an APM must meet the following three criteria:
What is CJR in Medicare?
The CJR program is another means for Medicare to tie payment to quality of care vs quantity of care. By making the providers, or “players” responsible for managing the total cost of care for each beneficiary, communication between post-acute care settings can be improved, thus improving cost and coordination of care.
When does the CJR end?
Designed as a 5-year test, the CJR model begins April 1, 2016, and ends December 31, 2020. Participating hospitals bear the financial risk {or reward} of the episode of care, which include the procedure, inpatient stay, hospital care, post-acute care, and provider services for 90 days.
What is Medicare's goal?
Medicare’s goal is carefully managed and coordinated services to achieve good outcomes. Let’s hope this is true… as therapists should be the only ones controlling the amount of therapy. The last thing therapists want is to transition from a system that rewards more therapy to a system that rewards less therapy.
Does telehealth require a waiver?
Waiver of current law limitations on payment for telehealth services that will allow telehealth services to be furnished in the beneficiary’s home or place of residence. These waivers will not permit coverage and payment for telehealth services, such as physical therapy, that are not currently covered.
Who can participate?
Unlike other models, involvement in CJR is not voluntary for all participants.
How does it work?
CJR is very similar to BPCI in the way it incentivizes hospital groups to coordinate care through the entire patient episode in order to eliminate waste, reduce unnecessary utilization of costly post-acute care facilities, improve patient engagement to decrease readmission rates, and ultimately drive down care costs while maintaining quality of care..
How do the payments work?
The episode benchmark prices used to calculate hospitals’ target prices are based on a blend of a hospital’s own historical standardized spending and regional historical standardized spending on LEJR episodes, moving towards 100% regional pricing for Performance Years 4 and 5.
What about quality measures?
As for the quality measures used to calculate payment, CMS looks at several quantitative and qualitative metrics to create a composite quality score.
What about waivers?
In an effort to improve patient engagement and satisfaction, CMS has issued waivers for certain Fraud and Abuse laws that will allow participants offer certain incentives to patients to increase engagement. The incentives provided by must be reasonably related to the patient’s care and/or advance specific clinical goals of the CJR model.
How can I ensure success with CJR?
CJR aims to support better and more efficient care for beneficiaries as they undergo joint replacement. As part of this effort, CJR expects that participating hospitals will work with downstream providers of post-acute care in order to better coordinate utilization and avoid unnecessary costs.
How can Claris Reflex help?
Claris Reflex is an effective means for practices and disconnected care teams to coordinate care across several different modalities as patients prepare for and recover from total joint replacements.
Model Design
- The CJR Model is a Medicare Part A and B payment model that holds participant hospitals financially accountable for the quality and cost of a CJR episode of care and incentivizes increased coordination of care among hospitals, physicians, and post-acute care providers. A CJR episode is defined by the admission of an eligible Medicare fee-for-service beneficiary to a hospi…
How to Contact The Cjr Model Team
- If you have questions regarding the Model, you can contact the CJR model team by emailing CJR@cms.hhs.gov.
Additional Information
- The CJR Model Summary and Findings of the Third Evaluation Report 1. Video: Comprehensive Care for Joint Replacement Model - Third Annual Report Findings
Relevant Material
- MSA volume and inclusion criteria worksheet used in selecting 67 MSAs for 2015 final rule (XLS)
- MSAs by population and payments used in selecting the 67 MSAs for 2015 final rule (XLS)
- CJR/EPM Voluntary Participation and other changes Final Rule Press Release(December 2017)
- COVID-19 Emergency Blanket Waivers (PDF)
Fact Sheets
Participant Resources
- List or Participant Hospitals
1. List of Hospitals - July 2021 (XLS) | (PDF) 2. List of CJR Hospitals not participating in the model for PY6: XLS | PDF 3. List of CJR Hospitals prior to February 2018 (XLS) - FAQs
1. Frequently Asked Questions PY's 1-5 (PDF) 2. Frequently Asked Questions PY's 6-8 (PDF)
Evaluation Reports
- Latest Evaluation Report
1. Two Pager: At-A-Glance Report - Fourth Annual Report (PDF) 1.1. Comprehensive Care for Joint Replacement Model - Fourth Annual Report (PDF) 1.2. Comprehensive Care for Joint Replacement Model - Fourth Annual Report Appendices (PDF) - Prior Evaluation Reports
1. Two Pager: At-A-Glance Report - Third Annual Report (PDF) 1.1. Comprehensive Care for Joint Replacement Model - Third Annual Report (PDF) 1.2. Comprehensive Care for Joint Replacement Model - Third Annual Report Appendices (PDF) 1.3. Comprehensive Care for Joint Replacement …