Comments on CJR Model Three-Year Extension Proposed Rule

The Health Care Transformation Task Force commented on the Centers for Medicare and Medicaid Services (CMS) proposed rule 5529-P addressing proposed changes to the Comprehensive Care for Joint Replacement (CJR) model (Proposed Rule).

HCTTF members have developed, operated, and participated in various alternative payment models, including Bundled Payments for Care Improvement (BPCI), BPCI Advanced, the Oncology Care Model, and CJR. We believe these models present key opportunities for providers to invest in improving quality and reducing health care expenditures. We applaud CMS’s commitment to the ongoing refinement of bundled payment models and encourage continued efforts to expand opportunities for organizations to take on more advanced risk and accountability for total cost of care and outcomes for Medicare beneficiaries.

Task Force Response Highlights

  1. General Comments. HCTTF supports the decision to incorporate outpatient hip and knee arthroplasty into the CJR model and the proposal to extend the model for an additional three years to test changes to the methodology. We recommend that CMS amend 42 C.F.R. 510.205 to clarify beneficiary exclusion criteria when attribution could be made to the Direct Contracting model. Additionally, we urge CMS to avoid creating arbitrage opportunities when considering overlap with other models.
  2. Feedback on Provisions of the Proposed Rule.
    • Episode Definition: We encourage CMS to ensure that any changes to the CJR model payment policy account for the range of patient complexity and the underlying operating costs for sites treating more complex patients to avoid unnecessarily penalizing high quality providers.
    • Target Price Calculation: If CMS is committed to moving to the use of a single year of data we request that CMS exclude or adjust 2020 data from their methodology due to the likely quality and comparability issues resulting from the COVID-19 Public Health Emergency and request that CMS clearly explain how it intends to adjust for these factors.
    • Reconciliation: We request that CMS provide additional clarity on the transition period and consider strategies to mitigate any cash flow issues. We also urge CMS to incorporate details on the planned approach for claims data sharing during the proposed model extension into the final rule, as monthly routine claims data sharing is essential to participant efforts to monitor their performance and improve the quality of care; provide model participants with data on how these adjustments would have impacted their prior years’ payments to assist them in preparing for the extended model period; publicly release more details on the regression analysis that identified the CMS-HCC condition count and age bracket as the most impactful adjustment factors; and consider methodologies to incorporate trend factors directly into the target price on a prospective basis while retaining reasonable shared savings potential for both CMS and model participants.
    • Elimination of 50 Percent Cap on Gainsharing: The Task Force supports the proposal to eliminate the 50 percent cap on gainsharing payments, distribution payments, and downstream distribution payments.
    • Quality Measures and Reporting: The Task Force supports the proposal to increase the quality score adjustment to a 1.5 percentage point reduction to the applicable discount factor for participant hospitals with ‘‘good’’ quality performance and a three-percentage point reduction to the applicable discount factor for participant hospitals with ‘‘excellent’’ quality performance. We encourage CMS to reconsider the feasibility of the proposed 100 percent reporting requirement for successful THA/TKA voluntary data submission. We also urge CMS to provide feedback in the final rule on the status of patient reported outcome (PRO) data collected as part of the CJR model and what progress has been made toward developing a suitable PRO measure for LEJR procedures. Finally, we urge CMS to incorporate health equity into the model evaluation approach by stratifying outcome measure data by race, ethnicity, and socioeconomic status.
    • Three Year Model Extension: We encourage CMS to keep model participation open to current CJR voluntary participants through the three-year extension period.

Read the Letter Here


Letter submitted on April 24th, 2020.