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

f S

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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)