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Comprehensive Care for
Joint Replacement (CJR)
Final Rule
November 17, 2015
What is CJR?
Mandatory bundled payments for 90-day hip/knee replacement
episodes
Acute care hospital is at risk for financial and quality
performance
Applies to Medicare FFS beneficiaries only
Applies to hospitals in 67 Metropolitan Statistical Areas (MSAs)
Runs for five years beginning April 1, 2016 and ending
December 31, 2020
Major Modifications from
Proposed Rule
1. Elimination of 8 MSAs
2. Delay of implementation date to April 1, 2016
3. Easing of transition to downside risk
4. Modifications to 3-Star
5. Changes to quality metrics and measurement
approach
Eliminated MSAs
• Colorado Springs, CO • Fort Collins, CO
• Medford, OR • Rockford, IL
• Evansville, IN-KY • Las Vegas-Henderson-Paradise, NV
• Richmond, VA • Virginia Beach-Norfolk-Newport News, VA-NC
-
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# o
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NF
s# SNFs Per MSA
AHCA members
Non-members
AHCA
Recommendations
Test PAC-only Bundle
CMS Response: CMS did not take recommendation,
but indicated that future rulemaking may include
opportunity for a PAC-only model:
“We may consider, through future rulemaking, other
episode of care models in which PGPs or PAC providers
are financially responsible for the costs of care”
Modify Five-Star Requirement
for 3-Day Stay Waiver
Originally proposed only 3 stars or higher SNFs are
eligible for waiver
CMS Response: SNFs rated 3 stars or higher for at
least 7 of the preceding 12 months are eligible for
the waiver
Waiver begins in year two of the program
* SNFs need to maintain 3 Stars for at least 7 of 12 months; analysis based on
estimate using data from Nursing Home Compare since the CMS rebasing in
Feb 2015.
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% SNFs satisfying 3-Star criteria to waive 3-day stay
Functional Outcome Measure
Requested inclusion of functional outcome measure to
prevent stinting on care
CMS Response: Hospitals will receive a composite
score based on performance in 3 quality measures
Complications following surgery measure (50%)
Consumer Satisfaction based on hospital CAHPS
survey (40%)
Submitting outcome data to CMS (10%)
SNFs Can Gain-share with
Hospitals
Hospitals may share in savings with other provider
entities (“Collaborators”) including SNFs
Collaborators must be providers or suppliers
Collaborators cannot be non-provider third-party
administrator/convener entities
Hospitals can share up to 50% of their total financial
risk with Collaborators
How to Succeed in CJR
Share Data with Hospitals
Collect your performance data to share with hospitals
Rehospitalization rate during SNF stay and after
SNF discharge
Discharge to Community Rate
LOS
Satisfaction score
Available through Long Term Care TrendTracker
Maintain 3 Stars or Better
Quality improvement resources available at
www.ahcancal.org/quality_improvement
Care Transitions
Develop robust transitions of care program
Arrange follow-up and communicate with primary
care MD
Do follow-up calls to discharges to community
within 24 hours and 3-5 days later
Next Steps for AHCA
CJR webpage goes live next week
AHCA will host an in-depth webinar in early December
Staff developing toolkit of resources for members
Data analytic tools
Suggested business strategies
Member Learning Collaborative at webpage
Using LTC TrendTracker
to Prepare
DC to community
LOS
Rehospitalization
Summary PAC Measure Report
www.ahcancal.orgahcancal
ahcancal
Background Slides
Payment & Pricing: Risk Structure
Hospitals bear the financial responsibility
Retrospective, bundle risk model applies to hospitals
Providers and suppliers will be paid via Medicare FFS
After a performance year, actual 90-day episode
payments will be compared to a target price
If actual payments are less than target price, hospital may receive
a bonus payment
If actual payments are more than target price, hospitals will be
responsible for making payment to Medicare
Payment & Pricing: Link to Quality
Hospitals must also do well on a quality composite score of
three quality measure in order to receive bonus payments:
1. Hospital Level Risk Standardized Complication Rate (RSCR)
for elective THA or TKA
2. Satisfaction based on Hospital Consumer Assessment of
Health Care Providers and Systems (HCAHPS) Survey
3. Outcome measure related to the patient’s pain control that
the hospital can collect and submit to CMS
Hyperlinks to CMS Materials
Factsheet
Final Rule (display copy)
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