The Final Rule announced by the Centers for Medicare and Medicaid Services (CMS) on April 29, 2021 encompasses a key set of changes to the Comprehensive Care for Joint Replacement (CJR) model. The CJR payment program was initially launched in April, 2016 to facilitate payment policies for hip and knee replacement surgeries.

The CJR model, which was originally mandatory for healthcare organizations in 67 Metropolitan Statistical Areas (MSAs) has massively evolved to 472 hospitals currently participating in the program. This payment model, which was scheduled to terminate by the end of 2021 has now been extended until December, 2024 with various revisions to further leverage the capabilities and benefits of the program.

The CJR payment program is extended for another three years considering the positive impact on the hip and knee replacement surgeries and their payment policies to aid better care. However, CMS has made several modifications, as needed, to the CJR model. These changes pertain to Medicare policy that would largely have an impact on the CJR payment program as well.

Here are key takeaways from the CMS’ Final Rule.

Final Rule to Continue. One of the key revisions to the rule is that the rule will extend until 2024 to evaluate the efficiency and impact of the model. The Final rule states that this will be extended to performance year 6,7 and 8 which will run through the end of December 2024.

Reimagining Orthopedic Care. The CJR model initially supported only Inpatient Patient Only List (IPOL) which Medicare reimbursed for inpatient care. However, the revised program includes support and Medicare reimbursement for Total Knee Arthroplasties and Total Hip Arthroplasties for outpatient care as well. The CJR program will also implement a blended pricing structure for inpatient and outpatient care to ensure optimal outcomes.

Changes to Target Price Calculation. The target prices for the CJR model were set based on historical data of three years of regional spending data. Although, the updated CJR model takes into consideration national factors along with hospital-specific data and has significantly increased the spending cap.

Reconciliation Frequency. Reconciliation in the current CJR model happens twice every end of the performance year. Alternatively, the new revisions have cut it down to one reconciliation after a performance year to drive down costs, while maximizing efficiencies.

Who can be part of the Program? The current CJR model has been mandated for 34 Metropolitan Statistical Areas except for rural hospitals who could opt-in to be part of the program. However, this rule has been revised with new participating criteria for specific hospitals.

Beneficiary Notification. The addition of the outpatient procedures to the CJR model has enabled changes to the beneficiary notification timings. It is mandatory that beneficiary notification is given before discharge for outpatient care. Also, the hospital needs to provide a written statement pertaining to any liabilities.

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In a patient-centric environment and a world of value-based care, it is critical that healthcare organizations focus on Patient Experience (PX) and engagement. The extension of the CJR model ensures that care providers continue to deliver the highest quality of care and are accountable for the cost and quality of care delivered.

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