• Compliance Matters

    The Comprehensive Care for Joint Replacement Model

    A new Medicare payment initiative offers patients and PTs a bundle of opportunities.

    More than 1 million total hip and total knee procedures were performed in the United States in 2014, approximately half of which were covered under Medicare.1 Physical therapists (PTs) are integrally involved in the care of these patients, providing postoperative care services to the vast majority of them.2 So, it's no surprise that last fall PTs anxiously awaited the final rule on a 2016 model project announced by the Centers for Medicare and Medicaid Services (CMS) that bundles payment for lower extremity joint replacement surgery.

    The project, the Comprehensive Care for Joint Replacement (CJR) model, is by no means an isolated initiative. In its most historic move since passage of the Affordable Care Act of 2010 (ACA), the US Department of Health and Human Services (HHS) early last year released an aggressive timeline for moving away from fee-for-service payment systems and toward those that reward PTs and other health care providers for improved patient outcomes.

    This effort includes integration of pay-for-performance initiatives such as value-based purchasing, as well as implementation of alternative payment models. Until now, participation in models such as accountable care organizations and bundled payment has been voluntary, but this soon will change. On April 1, CMS will implement the CJR in designated metropolitan areas as the first mandatory bundled care system. Per the rules released in November, the program will run for 5 years, ending on December 31, 2020, and will be administered by the Center for Medicare and Medicaid Innovation, which was created under the Affordable Care Act of 2010.

    Why the focus on hip and knee replacements? CMS offers 2 main reasons for the emphasis on these procedures. First, hip and knee surgeries are the most common inpatient procedure for Medicare beneficiaries. Second, these tend to be high-cost, high-utilization surgeries whose cost varies greatly—ranging from $16,500 to $33,000 per procedure. Medicare notes that more than 400,000 total hip knee and total knee procedures were performed in the United States in 2014, at a cost of more than $7 billion for the hospitalization portion of recovery alone.

    CMS, therefore, hopes the CJR model will standardize care and contain costs, while maintaining quality of care. The program will give hospitals and clinicians an incentive to work together to ensure that beneficiaries get the coordinated care they need at reduced cost. Participants in the model are encouraged to redesign care to achieve these goals.

    What Is the CJR Model?

    CMS has selected 67 metropolitan statistical areas to participate in this bundled payment system (see list on facing page). Patients undergoing total knee and total hip replacement—coded "MS-DRG 469: major joint replacement or reattachment of lower extremity with major complications or comorbidities," or "MS-DRG 470: major joint replacement or reattachment of lower extremity without major complications or comorbidities"—who receive care at a participating hospital will be included in the model.

    Hospitals will be given target case rates for these episodes that will include the costs of the inpatient stay and all related care through 90 days post discharge. These target prices will be updated each year for the model's duration, and CJR hospitals will be given separate episode target prices for patients with MS-DRG 469 and 470 codes that incorporates risk stratification for those with hip fractures.

    All providers participating in this model will continue to be paid under their respective payment systems. At the end of the year Medicare will reconcile the episodes and, depending on the hospital's quality performance, an institution may be eligible for additional payment if total spending is less than the Medicare episode rate. Alternatively, a participating hospital will be required to pay back some portion of the difference if total spending is above the Medicare episode rate based on established percentages.

    Hospitals can contract with various collaborators to share episode risk and savings. These collaborators can include groups and professionals across the continuum of care who provide services to this patient population—including PTs, physicians, home health agencies, skilled nursing facilities, long-term care hospitals, physician group practices, inpatient rehabilitation facilities, and nonphysician practitioners.

    To allow hospitals to adjust their internal processes and clinical practices for optimal success under the CJR model, CMS has indicated it will waive the repayment requirement during the model's first year for hospitals that exceed the target rate. Repayment amounts gradually will increase over the remaining years of the model: 5% in year 2, 10% in year 3, and 20% in years 4 and 5.

    To help ensure that lower costs do not compromise care, Medicare has included quality reporting in the CJR model. For the first year, the agency is requiring 2 quality measures: (1) hospital-level risk-standardized complication rate following elective primary THA (total hip arthroplasty) and/or TKA (total knee arthroplasty)—National Quality Forum measure 1550, and (2) the survey measure of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). In addition, Medicare is allowing participating facilities to submit patient-reported outcome measures. Accepted global measures of patient function are PROMIS (the Patient Reported Outcome Measurement Information System) or the Veterans Rand 12-item health survey. Accepted condition-specific patient-reported outcome measures are the Hip Disability and Osteoarthritis Outcome Score (HOOS) or the Knee Injury and Osteoarthritis Outcome Score (KOOS).

    CMS also has included several waivers in the CJR model to decrease the regulatory burden and help providers redesign the care pathway. For example, the agency will waive the 3-day hospital stay for these patients if they go to a nursing home with a 3-star or better rating on Hospital Compare. Also, telehealth services may be provided for these patients by professionals who are able to bill for such services under Medicare (which does not include PTs at this time).

    In the CJR model, beneficiaries retain freedom to choose services and providers. Providers are expected to continue to meet Medicare's current required standards. All existing safeguards to protect beneficiaries and patients remain in place.

    HHS's Office of Inspector General (OIG), furthermore, has released guidance on certain fraud and abuse laws, such as gainsharing civil monetary penalties, that will be waived to allow hospitals to distribute incentive payments to PTs and other providers.

    How Will This Affect PTs?

    PTs who practice in the affected metropolitan areas and see these patient populations will continue to be paid under their normal payment structure. Private practice PTs in these areas should consider whether to enter into formal collaborator agreements with local hospitals. Hospitals may ask collaborators to share a portion of the financial risk as well as sharing in the savings. Physical therapists who are considering entering into a collaborator agreement must understand how the model may impact their practice—taking into account patient volume, costs, and outcomes. Physical therapists in home health care or skilled nursing settings may also work in facilities who choose to enter into a collaborator agreement with participating hospitals.

    Innovative models such as CJR offer PTs opportunities for less-fragmented patient care, greater freedom to design care to meet best practices, expanded practice, and increased interdisciplinary teamwork. These opportunities bring challenges, as well, such as contracting complexities and electronic medical record compatibility with other providers in the bundle.

    What Is APTA Doing?

    APTA has developed a CJR webpage at www.apta.org/BundledModels/CCJR/ that features resources for members, including basics, contracting considerations, clinical practice guidelines and best practices, and information on functional tools included in the model.

    The association also offers a page within the Innovative Models community on the APTA Hub where members can share information about their experiences with the CJR model and engage in dialogue with other participants.

    In addition, APTA will offer a number of live educational opportunities throughout 2016 to ensure that members are kept abreast of the latest program-compliance and implementation-management issues. Look for announcements in PT in Motion News and through the APTA Learning Center at www.apta.org.

    Drummond-Dye, Roshunda 75x110

    Roshunda Drummond-Dye, JD, is director of regulatory affairs at APTA.  

    Smith, Heather 75x110

    Heather Smith, PT, MPH, is the association's director of quality.  


    1. Centers for Disease Control and Prevention. FastStats - Inpatient Surgery webpage. http://www.cdc.gov/nchs/fastats/inpatient-surgery.htm. Last updated April 29, 2015. Accessed January 5, 2016.
    2. Snow et al. Associations between preoperative physical therapy and post-acute care utilization patterns and cost in total joint replacement. J Bone Joint Surg Am. 2014;96(19). http://jbjs.org/content/96/19/e165. Accessed January 5, 2016.

    HHS Framework for Alternative Payment Models And Value-Based Payment

    HHS sets measurable goals and a timeline to move from volume to value.

    Goal is to tie payment to alternative payment models and pay for performance.

    30% of Medicare fee-for-service tied to alternative payment models, and 85% of Medicare fee-for-service tied to reporting quality outcomes by the end of 2016.

    50% of Medicare fee-for-service tied to alternative payment models, and 90% of Medicare fee-for-service tied to reporting quality outcomes by the end of 2018.

    Metropolitan Statistical Areas Included in the CJR model

    Akron, OH

    Albuquerque, NM

    Asheville, NC

    Athens-Clarke County, GA

    Austin-Round Rock, TX

    Beaumont-Port Arthur, TX

    Bismarck, ND

    Boulder, CO

    Buffalo-Cheektowaga-Niagara Falls, NY

    Cape Girardeau, MO-IL

    Carson City, NV

    Charlotte-Concord-Gastonia, NC-SC

    Cincinnati, OH-KY-IN

    Columbia, MO

    Corpus Christi, TX

    Decatur, IL

    Denver-Aurora-Lakewood, CO

    Dothan, AL

    Durham-Chapel Hill, NC

    Flint, MI

    Florence, SC

    Gainesville, FL

    Gainesville, GA

    Greenville, NC

    Harrisburg-Carlisle, PA

    Hot Springs, AR

    Indianapolis-Carmel-Anderson, IN

    Kansas City, MO-KS

    Killeen-Temple, TX

    Lincoln, NE

    Los Angeles-Long Beach-Anaheim, CA

    Lubbock, TX

    Madison, WI

    Memphis, TN-MS-AR

    Miami-Fort Lauderdale-West Palm Beach, FL

    Milwaukee-Waukesha-West Allis, WI

    Modesto, CA

    Monroe, LA

    Montgomery, AL

    Naples-Immokalee-Marco Island, FL

    Nashville-Davidson-Murfreesboro-Franklin, TN

    New Haven-Milford, CT

    New Orleans-Metairie, LA

    New York-Newark-Jersey City, NY-NJ-PA

    Norwich-New London, CT

    Ogden-Clearfield, UT

    Oklahoma City, OK

    Orlando-Kissimmee-Sanford, FL

    Pensacola-Ferry Pass-Brent, FL

    Pittsburgh, PA

    Port St. Lucie, FL

    Portland-Vancouver-Hillsboro, OR-WA

    Provo-Orem, UT

    Reading, PA

    Saginaw, MI

    San Francisco-Oakland-Hayward, CA

    Seattle-Tacoma-Bellevue, WA

    Sebastian-Vero Beach, FL

    South Bend-Mishawaka, IN-MI

    St. Louis, MO-IL

    Staunton-Waynesboro, VA

    Tampa-St. Petersburg-Clearwater, FL

    Toledo, OH

    Topeka, KS

    Tuscaloosa, AL

    Tyler, TX

    Wichita, KS


    Do you know where I can find a list of physical therapy practices in Durham - Chapel Hill that are practicing the CJR model?
    Posted by Mahek on 5/25/2016 10:34:11 AM

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