In April 2016, the Centers for Medicare and Medicaid Services (CMS) rolled out the Comprehensive Care for Joint Replacement (CJR) model with the specific goal of increasing the quality and cost efficiency for the two most common inpatient surgeries for Medicare beneficiaries: hip and knee replacements. Like other value-based models employed by CMS, the primary focus is on improving the coordination of care throughout the entire patient episode, from pre-surgical preparation to discharge from post-acute care.
Who can participate?
Unlike other models, involvement in CJR is not voluntary for all participants. While some rural and low volume providers were afforded the opportunity to opt-in or out of years 3 through 5 of the current CJR model, hospitals that are paid under the Inpatient Prospective Payment System (IPPS) and located in one of the 67 geographic areas set forth by CMS are still required to participate in CJR.
The CJR model runs until December 31, 2020. Currently, there are over 450 hospitals participating across the 67 geographic areas.
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.
Like BPCI models, the episode of care is defined from the initial joint replacement procedure until 90 days post-discharge and participating groups are given a target price for each episode based on historical claims costs for the procedure type.
One key difference, though, is while CJR participants still have the opportunity for gainsharing based on their performance against target price, they are not accountable to the same extent for downside risks as BPCI participants.
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. Regional historical standardized spending is also used to calculate the target price for any hospital with fewer than 20 LEJR episodes in the baseline period. They incorporate the 3% discount that we use to calculate prospective target prices, which may be further adjusted at reconciliation based on composite quality score.
Payments are reconciled retrospectively on an annual basis.
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. Some of the metrics taken into account are claims-based measures such as increases in readmissions and emergency room visits, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) satisfaction and care experience measures, and functional performance change scores from the required patient assessment instruments in home health agencies and skilled nursing facilities, as well as a beneficiary survey created by CMS in order to assess the impact of the CJR model on beneficiary perceptions of access, satisfaction, pain, mobility and other relevant functional performance measures.
For more information on Quality Score calculations and how they affect payment reconciliation, please see CMS’s FAQ for CJR.
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.
For more information on the requirements and limitations of these waivers, please see the official notice issued by CMS on January 1st, 2018
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.
The most successful groups will be the ones who proactively redesign workflows, implement standardized care protocols, and incorporate new technologies that allow more effective monitoring and coordination of patient populations as they move between different care settings.
It is crucial for participating group to assess their current operating procedures in order to determine any potential lapses in care coordination, which areas of post-acute care can be utilized more efficiently, and what opportunities exist to cultivate and sustain better patient engagement throughout the entire episode.
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. Using the integrated Claris platform, members of the care team are able to efficiently track, coach and monitor their patients throughout the entire episode of care, while our proprietary CareDot system automatically triages patients based on associated risk levels so that workflow and resources can be redirected to those patients that need it the most.
The flexibility and mobility of the Claris Reflex system allows case managers and other members of the care team to follow patients as they move throughout the continuum of care, providing a safety net that will prevent patients from falling through the cracks as they discharge to and from different clinical settings. Clinicians are also able to receive and respond to actionable, customizable alerts via our mobile caregiver app, online caregiver console, or email, allowing them to react to adverse events in real-time and prevent costly readmissions.
Patients using the Claris Reflex system have reported exceptionally high levels of engagement and satisfaction throughout their preparation and recovery from joint replacement. Given the weighting of these factors in the reconciliation process for CJR participants, Claris Reflex serves as an invaluable tool to ensure patients stay engaged, satisfied, and on-track throughout their clinical episode.