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The US Centers for Medicare and Medicaid Services (CMS) has issued a final rule on bundled care that largely mirrors what the agency proposed in August: a scaled back knee and hip joint replacement bundled care model—albeit with more opportunities for participation by individual providers—and cancellation of a plan to expand bundled care models to cardiac care and hip and femur fractures.

Known as the Comprehensive Care for Joint Replacement (CJR) model, the hip and knee bundle program launched in 2016 was the first-ever attempt by CMS to mandate bundled care. The rule as it now stands applies to 67 different geographic areas covering some 800 hospitals: beginning in 2018, the number of geographic areas required to participate in CJR would drop to 34, leaving participation voluntary for all hospitals in the other 33 areas. CMS estimates that 430-450 facilities will participate in the CJR next year, a number that includes facilities participating voluntarily.

In addition to reducing the number of geographic areas required to participate in the CJR, the final rule also follows through on a CMS proposal to switch low-volume and rural hospitals in the remaining 34 areas from mandatory to voluntary participation. A CMS fact sheet summarizes the changes in store for 2018.

At the same time CMS pulls back on the reach of the CJR, it is making it easier for clinicians, including physical therapists (PTs), to be included as qualifying alternative payment model (APM) participants (QPs) under the Quality Payment Program’s Advanced APM track. By expanding the ways providers can make it onto a CMS "affiliated practitioner list" to include clinicians whose contractual relationship with a facility supports a hospital's CJR goals, the new rule would deepen the pool of providers eligible to receive the Advanced APM 5% incentive payment. CMS will continue to maintain ultimate authority for who does and doesn't qualify as a QP, based on Medicare Part B claims data, but says it won't establish a specific threshold a clinician must meet to be considered supportive of a facility's CJR goals.

The expansion of the requirements to be considered a QP is good news for physical therapists but is tempered by other factors. The reduction of the number of hospitals in the mandatory program will dampen the effects of the change, as will the fact that the increased participation options apply only to facilities participating in "Track 1" of the CJR program—a version with more stringent requirements that also puts facilities at more financial risk.

As for expansion of mandatory bundling programs into other areas, that's no longer in the works. Just as proposed, the final rule halts a planned expansion of mandatory bundling to cardiac care, as well as expansion of the CJR to include care for hip and femur fractures. Those expansions originally were set to begin in February of this year but were delayed until October 1, and then pushed back again to a January 2018 startup date. The rule effectively cancels those programs altogether.

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