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CJR Model: Three - Year Extension and Changes to Episode Definition and Pricing and Additional Relevant Rulemaking - Comprehensive Care for Joint ...
Comprehensive Care for
                          Joint Replacement Model

CJR Model: Three-Year Extension and Changes to Episode
Definition and Pricing and Additional Relevant Rulemaking

                                Comprehensive Care for Joint
                                   Replacement Model

                                             May 2020

                                Audio available through device speakers
CJR Model: Three - Year Extension and Changes to Episode Definition and Pricing and Additional Relevant Rulemaking - Comprehensive Care for Joint ...
Webinar Agenda
• Welcome
• Meeting Logistics
• Proposed Rule Presentation
• Interim Final Rule With Comment Period Presentation
• Inpatient Prospective Payment System FY 2021 Proposed
  Rule Presentation
• Public Comment Submission Instructions
• Announcements & Reminders

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                      Joint Replacement Model             2
CJR Model: Three - Year Extension and Changes to Episode Definition and Pricing and Additional Relevant Rulemaking - Comprehensive Care for Joint ...
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CJR Model: Three - Year Extension and Changes to Episode Definition and Pricing and Additional Relevant Rulemaking - Comprehensive Care for Joint ...
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    Comprehensive Care for
    Joint Replacement Model                 4
Comprehensive Care for
                            Joint Replacement Model

  Comprehensive Care for Joint Replacement (CJR) Model:
Three-Year Extension and Changes to Episode Definition and
                          Pricing

                     Heather Holsey, JD, MS
                       Matthew Fox, MPP
                       Sarah Mioduski, JD
           Center for Medicare & Medicaid Innovation
            Centers for Medicare & Medicaid Services

                                                       5
Disclaimer
This presentation was current at the time it was published or uploaded
onto the web. Medicare policy changes frequently, so links to the source
documents have been provided within the document for your reference.
This presentation was prepared as a service to the public and is not
intended to grant rights or impose obligations. This presentation may
contain references or links to statutes, regulations, or other policy
materials. The information provided is only intended to be a general
summary. It is not intended to take the place of either the written law or
regulations. We encourage readers to review the specific statutes,
regulations, and other interpretive materials for a full and accurate
statement of their contents.

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CJR Proposed Rule

• CMS published the proposed rule, ‘Medicare
  Program: Comprehensive Care for Joint Replacement
  Model Three-Year Extension and Changes to Episode
  Definition and Pricing’ on February 24, 2020
• Public comment period closes at 5:00 pm ET, June 23,
  2020 https://www.federalregister.gov/d/2020-08717

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                   Joint Replacement Model            7
CJR Proposed Rule Summary
• The rule proposes to change certain aspects of the CJR model
  including:
   –   Episode of care definition
   –   Target price calculation
   –   Reconciliation process
   –   Beneficiary notification requirements
   –   Appeals process
   –   Gainsharing caps
   –   Medicare program rule waivers
• The rule proposes to extend the CJR model for an additional 3
  years through December 31, 2023, to allow time to test the
  proposed changes.
• The proposed rule also solicits comment on future bundled
  payment models in the ASC setting.

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The CJR Model
• The Comprehensive Care for Joint Replacement (CJR)
  model aims to support better and more efficient care for
  beneficiaries undergoing a lower extremity joint
  replacement (LEJR).

• The model allows CMS to continue gaining valuable
  experience with episode payments for hospitals, and
  their collaborating post-acute care and other providers,
  with variety in utilization patterns and patient
  populations.
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CJR Participants
•   November 2015 Final Rule: Hospitals in 67 selected metropolitan statistical
    areas (MSAs), with limited exceptions. The MSAs were randomly selected
    from 294 eligible MSAs and presented in the final rule.

•   December 2017 Final Rule: Rural and low-volume hospitals selected for
    participation in the CJR model, as well as those hospitals located in 33 of the
    67 MSAs, were given a one-time option to choose whether to continue their
    participation in the model through December 31, 2020.

•   February 2020 Proposed Rule: CMS proposes the model changes and
    extension would apply only to those participant hospitals with a CMS
    Certification Number (CCN) primary address in the 34 mandatory MSAs. The
    model changes and extension would exclude participant hospitals in those
    mandatory MSAs that are “low-volume hospitals” or that have received a
    notification from CMS dated prior to October 4, 2020, that they have been
    designated as “rural hospitals” (each as defined in 42 CFR 510.2)

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CJR Episode Definition
•   Currently, CJR model episodes are initiated by an inpatient MS -DRG 469 or
    470 discharge of an eligible Medicare beneficiary from a CJR participant
    hospital.
     o The proposed rule proposes to change this episode definition in order
       to address the removal of Total Knee Arthroplasty (TKA) and Total Hip
       Arthroplasty (THA) from the inpatient-only (IPO) list, which allows
       these procedures to be reimbursed by Medicare when performed in
       the outpatient (OP) setting.
     o We are proposing that TKA and THA procedures performed in the OP
       setting will trigger a CJR episode. OP TKA episodes will be reconciled
       against the MS-DRG 470 without hip fracture target price, while OP
       THA episodes will be reconciled against either the MS-DRG 470 with
       hip fracture or without hip fracture target price, as applicable.

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CJR Payment and Pricing:
            Target Price Calculation
• Currently, CJR target prices are based on 3 years of historical data.
• The proposed rule proposes to set target prices based on one year
  (the most recently available year) of baseline claims data.
• Currently, based on 100% regional pricing
   o The proposed rule does not propose to change the regional pricing
     approach. However:
   o The proposed rule proposes to remove the use of anchor factors and
     weights.
   o We seek comment on the appropriateness of moving to a national pricing
     approach in future years of the CJR model.

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                           Joint Replacement Model                        12
CJR Payment and Pricing:
                  Reconciliation
•   The proposed rule proposes to add:
     o Additional risk adjustment for the age bracket and HCC count applicable to
       a beneficiary in a CJR episode; we will continue to use the presence or
       absence of a hip fracture in setting the CJR target prices.
     o A retrospective trend adjustment factor to better capture changes in
       service delivery patterns in the target price.
•   Currently, there are 2 reconciliation periods after each CJR performance year.
     o The proposed rule proposes to shift to one reconciliation period that
       would be conducted 6 months after the close of each performance year.

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                               Joint Replacement Model                           13
CJR Payment and Pricing:
               Linking Quality to Payment
•   The Composite Quality Score (CQS) determines whether a participant is eligible for a reconciliation
    payment (if savings are achieved beyond the quality-adjusted target price) and what effective discount
    percentage is applied to the CJR-episode benchmark price for reconciliation payment.
     o Currently, participants with unacceptable quality are not eligible for reconciliation payments and
       have an effective discount percentage of 3%.
           • The proposed rule does not propose to change this.
     o Currently, those with acceptable, good, or excellent quality are eligible for reconciliation payment
       and have an effective discount percentage of 3%, 2%, or 1.5%, respectively.
           • The proposed rule proposes to move to a 0% quality withhold for participants with excellent
             quality scores and a 1.5% withhold for good quality scores.
•   CJR participants with a higher level of quality performance would generally experience a lower
    effective discount percentage at reconciliation, resulting in greater financial opportunity for the CJR
    participant.

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CJR Payment and Pricing:
          High Cost Episode Cap
• We currently apply a cap at 2 standard deviations above the
  regional mean (high episode payment ceiling) when calculating
  initial CJR target prices and when comparing actual CJR episode
  payments to CJR episode benchmark and quality adjusted target
  prices at reconciliation.
   o The proposed rule proposes to set the cap (high episode
      payment ceiling) at the 99% percentile of arrayed actual
      costs for each episode for each region (U.S. Census division).

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CJR Financial Arrangements:
Gainsharing Payments, Distribution Payments, and Downstream
                   Distribution Payments

•   Consistent with applicable law and regulations, CJR participant hospitals
    may engage in financial arrangements under the model.
•   CJR participant hospitals may share reconciliation payments and internal
    cost savings with collaborators.
•   Collaborators may share gainsharing payments as distribution payments to
    collaboration agents (physician group practice (PGP) members, non-
    physician practitioner group practice (NPPGP) members, ACO participants,
    or ACO providers/suppliers).
•   Collaboration agents that are PGPs or NPPGPs apart of a collaborator ACO
    may share distribution payments as downstream distribution payments to
    downstream collaboration agents who are physician group practice
    members or non-physician group practice members.

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                            Joint Replacement Model                             16
CJR Financial Arrangements:
Elimination of 50 Percent Cap on Gainsharing Payments, Distribution
         Payments, and Downstream Distribution Payments

 • In regards to physicians or non-physician practitioners, the CJR
   model has always included a cap on gainsharing payments,
   distribution payments, and downstream distribution
   payments.
 • We are proposing to eliminate the 50% cap on Gainsharing
   Payments, Distribution Payments, and Downstream
   Distribution Payments. It was determined that the existing
   cap:
        o Is arbitrary and limiting
        o Its burdens outweigh its benefits
        o Is consistent with BPCI Advanced policy
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CJR Program Rule Waivers:
        Skilled Nursing Facility (SNF)
• The CJR model waives the SNF 3-day rule for coverage of a SNF stay
  following the anchor hospitalization beginning in performance year 2.
• Beneficiaries discharged pursuant to the waiver must be admitted to
  SNFs rated 3-stars or higher on the CMS Nursing Home Compare
  website.
• Beneficiaries must NOT be discharged prematurely to SNFs, and they
  must be able to exercise their freedom of choice without patient
  steering.
• We propose to extend the 3 day SNF waiver to include beneficiaries
  who initiate CJR episodes in the outpatient setting.

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CJR Program Rule Waivers:
    Direct Supervision Requirement
•   The CJR model waives the direct supervision requirement to allow clinical
    staff to furnish certain post-discharge home visits under the general,
    rather than direct, supervision of a physician or nonphysician
    practitioners.

•   The waiver allows a CJR beneficiary who does not qualify for home health
    benefits to receive a maximum of 9 post-discharge visits.

•   We propose to extend the waiver of the direct supervision requirement
    for certain post-discharge home visits to include beneficiaries who
    initiate CJR episodes in the outpatient setting.

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CJR Beneficiary Protections:
        Beneficiary Notification
• The participant hospital notification informs Medicare
  beneficiaries of their inclusion in the CJR model and provides
  a paper, detailed explanation of the model.

• We propose changes to the requirements for when the
  participant hospital notification must be provided to
  Medicare beneficiaries receiving a CJR anchor procedure,
  whether inpatient or outpatient.

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Evaluation of the CJR model: Focus Areas

• The evaluation will assess the impact of the CJR model on the
  aims of improved care quality and efficiency as well as reduced
  health care costs.
• Focus areas include:
   o Payment and utilization impact
   o Quality of care and outcomes
   o Unintended consequences
   o Referral patterns and market impact
   o Potential for extrapolation of results

                         Comprehensive Care for
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Comprehensive Care for
                          Joint Replacement Model

Policy and Regulatory Revisions in Response to the
        COVID-19 Public Health Emergency
     Interim Final Rule with Comment Period

                   Heather Holsey, JD, MS
                     Matthew Fox, MPP
                     Sarah Mioduski, JD
         Center for Medicare & Medicaid Innovation
          Centers for Medicare & Medicaid Services

                                                     22
Interim Final Rule With Comment
             Period (IFC) [1]
• On April 6, 2020, CMS published an Interim Final Rule
  with Comment to make policy and regulatory revisions in
  response to the COVID-19 public health emergency,
  including programmatic changes to the CJR model
• These regulations are applicable beginning on March 1,
  2020.
• Instructions for submitting comments can be found in the
  proposed rule. To be assured consideration, comments
  must be received no later than 5 p.m. on June 1, 2020.

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Interim Final Rule With Comment
          Period (IFC) [2]
• 3-month extension to CJR performance year
  (PY) 5
  – CJR model will now end on March 31, 2021,
    rather than ending on December 31, 2020
• Update to the extreme and uncontrollable
  circumstances policy to account for episodes
  impacted by the COVID-19 pandemic

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Interim Final Rule With Comment
          Period (IFC) [3]
• Financial Safeguards
  – For a fracture or non-fracture episode with a date of
    admission to the anchor hospitalization that is on or
    within 30 days before the date that the emergency
    period begins (March 1, 2020) or that occurs through
    the termination of the emergency period, actual
    episode payments are capped at the target price
    determined for that episode under § 510.300.
  – Applies to all participant hospitals

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Comprehensive Care for
                        Joint Replacement Model

Inpatient Prospective Payment System (IPPS)
                  FY 2021

                 Heather Holsey, JD, MS
                   Matthew Fox, MPP
                   Sarah Mioduski, JD
       Center for Medicare & Medicaid Innovation
        Centers for Medicare & Medicaid Services

                                                   26
Inpatient Prospective Payment System
    (IPPS) FY 2021 Proposed Rule
• The Inpatient Prospective Payment System Fiscal Year 2021
  Proposed Rule proposes to create two new MS-DRGs, MS-
  DRG 521 (Hip Replacement with Principal Diagnosis of Hip
  Fracture with MCC) and MS-DRG 522 (Hip Replacement with
  Principal Diagnosis of Hip Fracture without MCC).
• CMS is seeking comment on the effect this proposal would
  have on the CJR model and whether to incorporate MS-DRG
  521 and MS-DRG 522, if finalized, into the CJR model’s
  proposed extension rule.
• Instructions and deadline for submitting comments can be
  found in the proposed rule.

                      Comprehensive Care for
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Comprehensive Care for
                        Joint Replacement Model

Public Comment Submission Instructions

                 Heather Holsey, JD, MS
                   Matthew Fox, MPP
                   Sarah Mioduski, JD
       Center for Medicare & Medicaid Innovation
        Centers for Medicare & Medicaid Services

                                                   28
When and Where Do I Submit
Comments For CJR Expansion Rule?
• The CJR Model proposed rule includes proposed changes not reviewed in this
  presentation. We will not consider feedback during this call as formal comments on
  the rule.
    o Reference the proposed rule for information on submitting these comments by
        the close of the comment period, which has been extended to June 23, 2020.
        When commenting, refer to file code CMS-5529-P.
• Instructions for submitting comments can be found in the proposed rule;
    o *Note-FAX transmissions will not be accepted.
• You must officially submit your comments via:
    o Regulations.gov (electronically)
    o Regular mail
    o Express or overnight mail
    o Hand/courier
• For additional information on the CJR model, please visit
  innovation.cms.gov/initiatives/cjr

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Comprehensive Care for
           Joint Replacement Model

Announcements & Reminders

                                     30
CJR Connect Guidance
•   All of the materials from this webinar are available on CJR Connect, in the CJR
    Libraries
     – If you don’t have a CJR Connect account, go to:
       https://app.innovation.cms.gov/CJRConnect/CommunityLogin and click “New User? Click
       Here”

•   A recent change to CJR Connect means that users who have not been active for 60
    days or more will have their accounts suspended.
     – To avoid suspension, users must log in at least once every 60 days.

•   If your CJR Connect account has been suspended and you want to regain access,
    follow the instructions below:
     – Email the CMMI Connect Help Desk at CMMIConnectHelpDesk@cms.hhs.gov or call 1-888-
       734-6433 (select option #2) and provide your name, organization, and any associated model
       identifiers (CCNs).

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Reminders
•   Public comment period for the CJR Proposed Rule closes at 5:00 pm ET on June
    23, 2020.

•   Public comment period for the Interim Final Rule with Comment Period closes at
    5:00 pm ET on June 1, 2020.

•   Feedback from this event WILL NOT BE CONSIDERED as formal comments on the
    aforementioned rules.

•   Send any questions or CJR model points of contact updates to
    CJRSupport@cms.hhs.gov.

•   To request a CJR Connect account, go to:
    https://app.innovation.cms.gov/CJRConnect/CommunityLogin and click “New
    User? Click Here.”

•   Please take a few minutes to respond to the Post-Event Survey.
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