Comprehensive Care for Joint Replacement Model Policy Changes and Cancellation of Episode Payment Models and Cardiac Rehabilitation Incentive Payment Model
(CMS-5524-F and IFC)

Comprehensive Care for Joint Replacement Model Policy Changes and Cancellation of Episode Payment Models and Cardiac Rehabilitation Incentive Payment Model (CMS-5524-F and IFC) 

Provider and Technical Fact Sheet 

On November 30, 2017, CMS announced a final rule and interim final rule with comment period in the Federal Register (https://www.federalregister.gov/public-inspection/current), which finalizes the cancellation of the Episode Payment Models (EPMs) and the Cardiac Rehabilitation (CR) Incentive Payment Model that were to begin on January 1, 2018 and implements changes to the Comprehensive Care for Joint Replacement (CJR) Model. 

Specifically, CMS is cancelling the Episode Payment Models (EPMs) and the CR Incentive Payment Model established by the Center for Medicare and Medicaid Innovation (Innovation Center) under the authority of section 1115A of the Social Security Act (the Act) and rescinding the regulations at 42 CFR part 512. 

This rule makes participation voluntary for all eligible hospitals in approximately half of the geographic areas selected for participation in the Innovation Center’s CJR Model (that is, in 33 of the 67 Metropolitan Statistical Areas (MSAs) selected; see the original CJR final rule, 80 FR 73299 Table 4, for a full listing of MSAs included in the CJR Model) and for low volume and rural hospitals in all of the geographic areas selected for CJR participation. A list of all CJR participant hospitals, their MSAs, the status (mandatory or voluntary) of their MSAs and their status as rural or low volume, if applicable has been posted on the CJR webpage at: https://innovation.cms.gov/initiatives/cjr for reference. 

We are also finalizing several technical refinements and clarifications for certain CJR Model payment, reconciliation, and quality provisions, and a change to the criteria for the Affiliated Practitioner List to broaden the CJR Advanced Alternative Payment Model (APM) track to additional eligible clinicians. 

Additionally, CMS is issuing an interim final rule with comment period in conjunction with this final rule in order to address the need to provide some flexibility in the determination of episode costs for providers located in areas impacted by extreme and uncontrollable circumstances such as the hurricanes of 2017. 

Participation Election (Opt In) for Certain MSAs and Low Volume and Rural Hospitals in the CJR Model

The CJR Model will continue on a mandatory basis in approximately half of the selected geographic areas (that is, 34 of the 67 selected geographic areas), with an exception for low volume and rural hospitals, and will continue on a voluntary basis in the other areas (that is, 33 of the 67 selected geographic areas). We are excluding low volume hospitals in the 34 mandatory participation MSAs, as identified by CMS as those hospitals having fewer than 20 CJR episodes in total across the 3 historical years of data, from required participation in the CJR Model beginning February 1, 2018. Low volume CJR hospitals that choose to voluntarily participate must make a one-time participation election that complies with the CJR regulations at § 510.115 or it will be automatically dropped from the CJR Model. We are also excluding rural hospitals (as defined in § 510.2) with a CMS Certification Number (CCN) primary address in the 34 mandatory participation MSAs from required participation in the CJR Model beginning February 1, 2018. Rural CJR hospitals that choose to voluntarily continue to participate must make a one-time participation election that complies with the CJR regulations at § 510.115 or it will be automatically dropped from the CJR Model. Hospitals eligible for voluntary participation who do not elect to participate will have all their performance year 3 episodes (i.e. those episodes ending on or after January 1, 2018 and before January 1, 2019) cancelled. A summary of the changes to the CJR Model participation requirements are shown in the table below. 

PARTICIPATION REQUIREMENTS FOR HOSPITALS IN THE CJR MODEL

*Note: Participation requirements are based on the CCN status of the hospital as of January 31, 2018. A change in rural status after the voluntary election period does not affect the participation requirements.

Participation Election Timing

We will hold a one-time participation election period for hospitals with a CCN primary address located in the voluntary participation MSAs and for specified low-volume hospitals and rural hospitals in the mandatory participation MSAs that begins January 1, 2018, and ends January 31, 2018. In order for a hospital to voluntarily continue to participate in the CJR Model, CMS must receive the hospital’s voluntary participation election letter no later than January 31, 2018. The hospital’s participation election letter will serve as the model participation agreement. For those hospitals that elect voluntary participation, the participation agreement will be effective February 1, 2018, and will continue through the end of the CJR Model. See the CJR Model website at https://innovation.cms.gov/initiatives/cjr for the voluntary election letter. 

Codification of CJR Model-related Evaluation Participation

This final rule adds provisions in § 510.410(b)(1)(i)(G) to specify that CMS may take remedial action if a participant hospital or its collaborators, collaboration agents, and downstream collaboration agents fails to participate in model‑related evaluation activities conducted by CMS and/or its contractors. 

Clarification of CJR Reconciliation Following Hospital Reorganization Events

Reorganization events that involve a CJR Model participant hospital and a hospital that is not participating in the CJR Model and result in the new organization operating under the CJR participant hospital’s CCN do not affect the reconciliation for the CJR participant hospital for episodes that initiate before the effective date of the reorganization event. Episodes that initiate after such reorganization event will be subject to an updated quality-adjusted episode target price that is based on historical episodes for the CJR participant hospital which will include historical episode expenditures for all hospitals that are integrated under CCN. These policies have been in effect since the start of the CJR Model on April 1, 2016. However, to further clarify this policy for the CJR Model, we added a provision specifying that separate reconciliation calculations are performed for episodes that occur before and after a reorganization that results in a hospital with a new CCN at § 510.305(d)(1). We believe this clarification increases transparency and understanding of the payment reconciliation processes for the CJR Model. 

Adjustment to the Pricing Calculation for the CJR Telehealth HCPCS Codes to Include the Facility Practice Expense (PE) Values

This final rule replaces the zero PE value currently used in the CJR Telehealth HCPCS Code pricing calculation with use of the facility PE relative value units (RVUs) for the analogous services in pricing the 9 CJR HCPCS G codes. We are also finalizing revisions to § 510.605(c)(2) to reflect the addition of the RVUs for comparable codes for the facility PE to the work and MP RVUs we are currently using for the basis for payment of the CJR telehealth waiver G codes.

Clinician Engagement Lists

To increase opportunities for eligible clinicians supporting CJR Model participant hospitals by performing CJR Model activities and who are affiliated with participant hospitals to be considered Qualifying APM Participants (QPs), we are finalizing that participant hospitals that choose to participate in the Advanced APM track would submit a clinical engagement list with information for each physician, non-physician practitioner, or therapist who is not a CJR collaborator during the period of the CJR Model performance year specified by CMS, but who does have a contractual relationship with the participant hospital based at least in part on supporting the participant hospital’s quality or cost goals under the CJR Model during the period of the performance year specified by CMS. The clinician engagement list will also be considered an Affiliated Practitioner List. The clinician engagement list and the clinician financial arrangement list are considered together an Affiliated Practitioner List and will be used by CMS to identify eligible clinicians for whom we will make a QP determination based on services furnished through the Advanced APM track of the CJR Model.

Clarification of Use of Amended Composite Quality Score Methodology During CJR Model Performance Year 1 Subsequent Reconciliation

We conducted the initial reconciliation for performance year 1 of the CJR Model in early 2017, and have made initial reconciliation payments to CJR participant hospitals that earned such payments for performance year 1. Preliminary year 1 reconciliation results are available on the CMS website at https://innovation.cms.gov/initiatives/cjr. We will conduct the subsequent reconciliation calculation for CJR performance year 1 beginning in the first quarter of 2018, which may result in additional amounts to be paid to participant hospitals or a reduction to the amount that was paid for performance year 1. However, the results of the performance year 1 subsequent reconciliation calculations will be combined with the performance year 2 initial reconciliation results before reconciliation payment or repayment amounts are processed for payment or collection.

Changes to the CJR Model established in the "Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model" final rule, published in the January 3, 2017 Federal Register (82 FR 180), impact this process. Specifically, the methodology used to determine the quality-adjusted target price for the performance year 1 subsequent reconciliation calculation will differ from the methodology used to determine the quality-adjusted target price for the performance year 1 initial reconciliation calculation, which may result in significant differences between the reconciliation payments calculated during the performance year 1 initial reconciliation and the performance year 1 subsequent reconciliation. To remedy this issue, we will apply the quality specifications as established in the final rule – that is, the amendments to §§ 510.305 and 510.315 that became effective May 20, 2017 -- to performance year 1 subsequent reconciliation calculations to ensure that reconciliation calculations for subsequent performance years will be calculated using the same methodology and to improve consistency across performance years for quality improvement measurement. Thus, for the reasons noted previously, we are not changing the amendments to §§ 510.305 and 510.315 that became effective May 20, 2017. 

Interim Final Rule Regarding Significant Hardship due to Extreme and Uncontrollable Circumstances in the CJR Model

We are issuing an interim final rule with comment period in conjunction with this final rule in order to address the need for a policy to provide some flexibility in the determination of episode costs for CJR hospitals located in areas impacted by extreme and uncontrollable circumstances. Specifically, this policy will apply to CJR hospitals located in areas for which a waiver under section 1135 of the Social Security Act has been invoked by the Secretary of Health and Human Services (the Secretary) if those CJR hospitals are also located in a county, parish, U.S. territory, or tribal government designated as a major disaster area under the Stafford Act. For performance years 2 through 5, for participant hospitals that are located in an emergency area during an emergency period (as those terms are defined in section 1135(g) of the Social Security Act), for which the Secretary has issued a waiver under section 1135, and are located in a county, parish, U.S. territory or tribal government designated as major disaster areas under the Stafford Act, the following policies apply for all CJR Model episodes. For non-fracture episodes with a date of admission to the anchor hospitalization on or within 30 days before the date that the emergency period (as defined in section 1135(g)) begins, actual episode payments are capped at the target price determined for those episodes under §510.300. For fracture episodes with a date of admission to the anchor hospitalization on or within 30 days before or after the date that the emergency period (as defined in section 1135(g)) begins, actual episode payments are capped at the target price determined under §510.300. 

The Advancing Care Coordination through Episode Payment Models final rule and interim final rule with comment period can be viewed at: https://www.federalregister.gov/public-inspection/current. For more information about the CJR Model, go to: https://innovation.cms.gov/initiatives/CJR.

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