CMS Announces Comprehensive Care for Joint Replacement Model:VTAgency Includes Waivers for Telehealth

On July 9, 2015, CMS announced the Comprehensive Care for Joint Replacement (“CCJR”) Model. The proposed initiative seeks to hold hospitals accountable for the quality and cost of care provided through the entire hip and knee surgery process. CMS is accepting comments on the proposed model until September 8, 2015.

The proposed two-year model is intended to support better and more efficient care for those patients undergoing hip and knee replacements (also known as lower extremity joint replacements or “LEJR”). The model is designed to test retrospective bundled payment of episodic care for these common surgeries that cost more than $7 billion for hospitalization alone in 2013. Ideally, hospitals, physicians, and post-acute care providers will work together to improve quality and coordination of care throughout the entire surgical and recovery process. Participating hospitals will be held financially accountable for the quality and cost of a beneficiary’s entire episode of care, which continues 90 days after discharge. The hospital will either be financially rewarded or penalized depending on the care provided.

In order to improve the effectiveness of care coordination, CMS will provide additional tools. CMS proposes to do the following:

1) Provide hospitals with relevant spending and utilization data to aid hospitals in developing their target price.

2) Waive certain Medicare requirements to encourage flexibility:

  • Waive the requirement for a three-day inpatient hospital stay prior to admission for a covered skilled nursing facility (“SNF”) stay under certain conditions.
  • Expand payment for telehealth services by removing geographic restrictions:

    • Proposal allows telehealth services to be furnished to eligible telehealth individuals when they are located at one of the eight originating sites without regard to the site meeting one of the geographic site requirements.
    • Further, the proposal removes the requirement that the eligible telehealth individual be in one of the eight approved originating sites when the otherwise eligible individual is receiving telehealth services in his or her home or place of residence, which will allow providers furnishing services to CCJR beneficiaries to utilize telemedicine for beneficiaries that are not classified as rural.

  • Allow certain types of physician-directed home visits for non-homebound beneficiaries.
  • Allow participating hospitals to enter into financial arrangements with collaborating providers and suppliers engaged in care redesign with the hospital and furnishing services to the beneficiary during a CCJR episode to share both payments and financial accountability.

3) Facilitate the sharing of best practices between participating hospitals with a learning and diffusion program.

physiciansThose hospitals currently participating in Model 1 or Phase II of Model 2 or 4 of the Bundled Payments for Care Improvement (“BPCI”) program will be unable to participate in the program because the agency has concerns that such participation would impair the ability of participants to succeed in the objectives of either program. Hospitals paid under the inpatient prospective payment system (“IPPS”) located in a metropolitan statistical area (“MSA”)—an urban area that has a population of at least fifty thousand people—and not involved in the BPCI models previously mentioned, will be required to participate in the program. Conversely, those hospitals located in non-MSA areas will be ineligible for the program.

The text of the proposed rule can be found at:

https://www.federalregister.gov/articles/2015/07/14/2015-17190/medicare-program-comprehensive-care-for-joint-replacement-payment-model-for-acute-care-hospitals#h-128.

Instructions for commenting on the rule can be found at http://www.cms.gov/Regulations-and-Guidance/Regulations-and-Policies/eRulemaking/index.html?redirect=/eRulemaking.

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