CMS finalizes hip, knee bundled payment program: 10 things to know

CMS has finalized a new payment model that holds acute care hospitals accountable for the quality of care they deliver to Medicare beneficiaries for hip and knee replacement from surgery through recovery.

Here are 10 things to know about the new Comprehensive Care for Joint Replacement Model.

1. Under the five-year CCJR program, hospitals will continue to be paid according to existing Medicare fee-for-service rules. However, the hospital where the surgery takes place will be held accountable for the quality and costs of care from the time of surgery through 90 days after discharge.

2. Under the payment model, hospitals are eligible to receive an additional payment or be required to repay Medicare for a portion of the episode costs depending on the quality of care the hospital provides and its cost performance.

3. "By 'bundling' payments for an episode of care, hospitals, physicians, and other providers have an incentive to work together to deliver more effective and efficient care," said CMS in a statement.

4. The CCJR Model will initially be implemented in 67 geographic areas — down from the original proposal of 75 areas.

5. Unlike other existing bundled payment programs, the CCJR Model would be mandatory for most hospitals in the 67 geographic areas that perform lower extremity joint replacements.

6. As of Nov. 16, approximately 800 hospitals are required to participate in the CCJR Model.

7. The CCJR Model is DRG-based. Under the program, the episode of care begins when a Medicare beneficiary is admitted to a participating hospital and is ultimately discharged under MS-DRG 469 or 470, and the episode ends 90 days post-discharge.

8. CMS proposed the CCJR Model in July, and the program was originally slated to begin Jan. 1, 2016. However, after reviewing nearly 400 comments from the public on the proposed rule, CMS pushed the program start date back until April 1, 2016. The CCJR program will conclude Dec. 31, 2020.

9. Although the final rule covering the new payment model does not include waivers for fraud and abuse laws, CMS and HHS' Office of Inspector General did issue a joint statement waiving the Anti-Kickback Statute, Stark Law and civil monetary penalty laws with respect to certain financial arrangements and beneficiary incentives under the CCJR Model.

10. Commenting on the CCJR program, AHA President and CEO Rick Pollack said the rule "takes several positive steps to provide the support hospitals need to be successful" as they redesign the way care is delivered to increase value and better serve patients.

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