INSIGHTS FOR HEALTH CARE 

JANUARY 21, 2016   
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Health Care News Network (HCNN), is published on an as-needed basis to keep you informed of current news impacting health care organizations.
 

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CMS Issues Final Rule: Bundled Payments for Comprehensive Care for Joint Replacement
 
CMS recently issued the final rule for Bundled Payments for Comprehensive Care for Joint Replacement (CJR). This rule implements retrospective bundled payments for episodes of care for hip or knee replacements in 67 metropolitan statistical areas (MSAs) across the country. The program begins April 1, 2016, and is mandatory for Medicare Fee-for-Service (FFS) beneficiaries in these MSAs.
 
Hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries and can require lengthy recovery and rehabilitation periods. In 2014, there were more than 400,000 procedures, costing more than $7 billion for the hospitalizations alone. Despite the high volume of these surgeries, quality and costs of care for these hip and knee replacement surgeries still vary greatly among providers.
 
The episode of care begins with an admission to a participant hospital of a beneficiary who is ultimately discharged under MS-DRG 469 or 470 and ends 90 days post-discharge in order to cover the complete period of recovery for beneficiaries. The episode includes all related items and services paid under Medicare Part A and Part B for all Medicare FFS beneficiaries, with the exception of certain exclusions.
 
Participating hospitals will be looking to partner with physicians, home health, SNF/Swing bed facilities or other alternative care arrangements in order to create a network of providers who can furnish services that are low cost and high quality. All providers and suppliers will be paid per the current payment rules (i.e., DRGs, fee schedule, RUGs, etc.) and then at fiscal year-end a reconciliation will be done. Please see the CMS website page on the Comprehensive Care for Joint Replacement Model for a list of the affected MSAs:
 
We recommend you review the list of MSAs to see if your community is identified. If it is, the next step is to determine how your hospital is currently involved (or would like to be) in treating CJR patients, and then begin evaluating your internal data to determine your ability to evaluate historical total cost of care and quality outcomes, as well as the volatility in these.
 
CMS is making available three years of historical claims-level detail to participating hospitals to help them understand their individual performance relative to their regional market. Hospitals need to make a one-time request by emailing cjr@cms.hhs.gov and provide two points of contact. The hospital CCN should be placed in the subject line of the request.
 
If you have questions about the CJR bundled payment, please discuss this with Marie White or contact your Eide Bailly client service representative.


   

Marie White
Health Care Reimbursement Manager

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