CJR – The Race to 30%!

In January, Health & Human Services (HHS) Secretary, Sylvia M. Burwell announced ambitious goals to transition Medicare hospital and physician payments from the fee-for-service structure towards value-based payments.  The first goal was to achieve 30% of payments through alternate payment models like ACOs and bundled payments by 2016. Among many programs, one strategy to achieve this target was the Comprehensive Care for Joint Replacement (CJR) Model announced in July.


What was somewhat surprising was the mandatory nature of the CCJR program. Historically, Medicare has announced models that start as pilots, move to demonstrations and then, once validated, became permanent voluntary programs.  The bundled payment program evolved from the Acute Care Episode (ACE) demonstration to the Bundled Payment for Care Improvement (BPCI) Initiative followed by the mandatory CJR Model.  Medicare proposed to test the mandatory CJR Model in 75 Metropolitan Statistical Areas (MSA) beginning January 1, 2016, for a period of 5 years.

Medicare received over 300 letters from interested parties prior to the September 8th comment deadline.  The overwhelming majority of comment letters submitted requested a delay in program implementation.

Even for those providers with sufficient resources and experience, many concurred with Trinity Health’s input, “Our experience suggests that it takes 6 to 12 months to prepare for BPCI.  Given the mandatory nature of the CJR program, all hospitals in the selected geographic areas deserve sufficient time to prepare and assure success.”

CJR proposes that baseline data will not be available “sooner than 60 days after January 1, 2016, the effective date of the model.”  The American Hospital Association is concerned, “that the proposed Jan. 1, 2016, start date does not provide adequate time for hospitals to put in place the care processes and procedures necessary to achieve success in the program.”

However, most comment letters expressed far greater concerns than the problematic implementation date.  Issues surrounding target price methodology, severity adjustment, episode definition, episode initiator role, collaborator expansion, fraud and abuse waivers, reconciliation timing, availability of historical baseline data, et al. were outlined in detail by trade associations and individuals alike.

While confident HHS will attain their 30% quantity to quality target, one idea to consider in addressing the CJR implementation date concern would be to open a new 90-day BPCI enrollment period prior to year-end, while postponing the start date of the mandated CJR  Model until October 1, 2016.  This would afford those providers who are ready to move forward, allow CMS the opportunity to fine-tune the proposed rule and put the remaining providers on notice that the mandatory CJR Model program will begin October 1, 2016.

Written by Richard S. Morgan on LinkedIn Pulse