Comprehensive Care for Joint Replacement (CJR)

Financial Agreements with Other Providers

Financial Agreements with Other Providers

• Since CMS considers care coordination critical for successful LEJR outcomes, they are allowing CJR hospitals to establish risk-sharing and gain-sharing relationships (“sharing arrangements” described in “collaborator agreements”) with other providers (“CJR collaborators”).

Financial Agreements with Other Providers

• When risk-sharing payments are made to a hospital by a CJR collaborator, CMS refers to the payment as an “alignment payment.” • A hospital that shares a reconciliation

payment with a CJR collaborator makes a “gainsharing payment.”

Types of collaboratorsHospitals can enter into collaborator agreements with the following types of providers:• Skilled nursing facility (SNF)• Home health agency (HHA)• Long-term care hospital (LTCH)• Inpatient rehabilitation facility (IRF)• Physician• Non-physician practitioner (mid-levels)• Provider or supplier of outpatient therapy services• Physician group practice (PGP)

How risk is shared?

• The CJR hospital must retain at least 50% of its repayment responsibility to CMS.

• A single CJR collaborator can take on no more than 25% of the hospital’s risk.

• The hospital is always ultimately responsible to CMS for repayments regardless of the existence of sharing arrangements.

Financial Agreements with Other Providers

• CJR hospitals have flexibility to enter into different arrangements with similar types of providers within the boundaries of the program.

Gainsharing• Gainsharing payments must be only

reconciliation payments, internal hospital cost savings or both.

• The cap on payments to individual physicians, PGPs and non-physician practitioners is 50% of the total MPFS for services furnished to the hospital’s CJR beneficiaries by that provider.

• CMS doesn’t specify how the agreement must calculate the gainsharing component.

Guidelines for Collaborator AgreementsThe following guidelines apply to collaborator agreements:• CJR collaborators must be Medicare providers or suppliers• Hospitals can distribute gainsharing payments only once per year• The duration of the agreements may be more than one year• Documentation of the agreement must be contemporaneous and

include a description, date, purpose, scope and financial terms• Hospitals must publish list of CJR collaborators on their website

and update it at least quarterly (it’s not necessary to list the dollar amount of payments)

• Collaborators must have furnished service included in the episode to CJR beneficiaries

Guidelines for Collaborator AgreementsAdditional guidelines that apply to collaborator agreements:• Payment arrangements must be proportional to the care

provided• Collaborators must be contributing to the care redesign

strategies of the CJR hospital• Beneficiaries retain full choice of provider• CJR collaborators must have full decision-making authority

regarding CJR patient care• Hospitals are responsible for ensuring that their CJR

collaborators comply with the requirements of the program

• There must be a quality requirement in the agreements

PGP and Individual Practice agreementsPGPs have the option of retaining some or all of the gainsharing payments received from CJR hospitals. Arrangements between PGPs and individual practice members are subject to certain requirements, including:• The agreement must be in writing• The arrangement must be voluntary for the individual

practitioner in the PGP• The agreement must require compliance with the CJR

final rule• Payments may not be contingent or based on volume

PGP and Individual Practice agreementsAdditional requirements between PGPs and individual practice members include:• The practitioner must have billed for an item or service for a

CJR beneficiary in the performance period• Payment to an individual must not exceed the total gainsharing

payment received• Payments must be made via EFT• The individual must retain the ability to make clinical decisions

in the best interest of the patient• The PGP must maintain documentation related to the

agreement• The individual can’t have a separate collaborator agreement

with the CJR hospital

To download the full CJR report, click on the image below