CJR and Clinical Data Registries—What You Need to Know

By now, everyone in the joint replacement profession has heard about the Centers for Medicare & Medicaid’s (CMS) final ruling on bundled payments—the Comprehensive Care for Joint Replacement (CJR) model—that was released in November 2015. Under CJR, hospitals within 67 geographic regions must bundle payments for lower extremity joint replacement (LEJR) procedures.

Members of the orthopaedic community are understandably concerned about how the ruling impacts them—particularly with respect to clinical data registry participation. The American Joint Replacement Registry (AJRR) has assembled a list of the top 12 things orthopaedic surgeons need to know about CJR and clinical data registries.

  1. The CJR model is about bundled payments. The CJR model aims to support better and more efficient care for CMS’ beneficiaries undergoing the most common inpatient surgeries for hip and knee replacements (also called LEJR). This model tests bundled payments and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery.
  2. The program is mandatory for 794 hospitals. The model is required for the 794 hospitals located in 67 Metropolitan Statistical Areas (MSAs) throughout the country. MSAs are counties associated with a core urban area that has a population of at least 50,000. The full list of MSAs in this program can be found at https://innovation.cms.gov/initiatives/cjr
  3. AJRR can help. AJRR currently collects LEJR data from at least one hospital in more than 50 percent of the mandatory areas. We are committed to helping the remaining hospitals meet the CMS mandate and will provide guidance and support to utilize our Registry to meet this model.
  4. The program begins on April 1, 2016. The first performance period for the CJR model will begin on April 1, 2016. CMS’ final ruling extended this date from Jan. 1, 2016. This performance period start date will provide hospitals with more time to prepare for participation by identifying care design opportunities, beginning to form financial and clinical partnerships with providers, and using data to assess financial opportunities under the model. The first end date for 2016 calendar year will be Dec. 31, 2016. Performance years 2017, 2018, 2019, and 2020 will include episodes that occur from Jan. 1 through Dec. 31 of each year.
  5. CMS updated the quality-based payment method. Instead of the proposed performance percentile thresholds for reconciliation payment eligibility, CMS is finalizing a composite quality score methodology. The composite quality score is a hospital-level summary quality score reflecting performance and improvement on the two quality measures finalized for this model (total hip arthroplasty [THA]/total knee arthroplasty [TKA] complications measure [NQF #1550] and the Hospital Consumer Assessment of Healthcare Providers and Systems patient experience survey measure [NQF #0166]) and successful reporting of THA/TKA patient-reported outcomes (PROs) and limited risk variable data. 
  6. Patient-reported outcome measures (PROMs) are currently not a mandatory component of the model. However, you can earn bonus points for voluntary PRO and risk variable submission. Hospitals can receive additional “points” toward earning reconciliation payments through voluntary submission of PRO and risk variable data. In Year 1, to qualify for bonus “points” for voluntary PRO and risk variable submission, hospitals must submit data for 50 percent or 50 elective primary LEJR procedures performed between July 1 and Aug. 31, 2016. For the first year of the program, PRO data must be collected 90 to 0 days prior to the LEJR procedure and submitted to CMS by Oct. 30, 2016.
  7. You will be able to use AJRR’s Level III platform to facilitate collection of PROs for your patients. AJRR Meets CJR’s Quality and Outcome Needs.
    • Measures for Quality and Outcome Assessment (AJRR’s Level III data elements)
      • Generic Quality of Life PRO measure: VR-12 or PROMIS 10 Global
      • Hip-Specific PRO measure: HOOS, JR (Hip disability and Osteoarthritis Outcome Score)
      • Knee-Specific PRO measure: KOOS, JR (Knee injury and Osteoarthritis Outcome Score)
    • Measures for Risk Adjustment (AJRR’s Level II data elements)
      • AJRR is adding the following risk variable data elements, which are required by CJR: patient-reported pain in nonsurgical lower extremity joint; patient-reported back pain (Oswestry Disability Index); patient-reported health literacy. 
      • AJRR can provide you with dashboard and benchmarks on comparative data from its Registry. You can use these reports to submit to CMS. 
  8. Hospitals need to submit all of the data on their own behalf. You do not need attestations or proof from us of your participation.
  9. The site where surgery was performed is held accountable. In the CJR model, the acute care hospital (ie, the site of surgery) will be held accountable for spending during the episode of care.
  10. The CJR is a retrospective bundled payment model. CMS will provide participant hospitals with Medicare episode prices, called the target prices, prior to the start of each performance year. Target prices for episodes anchored by Medicare Severity Diagnosis Related Group (MS-DRG) 469 vs. MS-DRG 470 and for episodes with hip fractures vs. without hip fractures will be provided to participant hospitals. The target price will include a discount over expected episode spending and combine a blend of historical hospital-specific spending and regional spending for LEJR episodes, with the regional component of the blend increasing over time. All providers and suppliers furnishing LEJR episodes of care to beneficiaries throughout the year will be paid under existing Medicare payment systems.
  11. Beneficiaries retain their freedom to choose services and providers. Physicians and hospitals are expected to continue to meet current standards required by the Medicare program. The rule also describes additional monitoring of claims data from participant hospitals to ensure that hospitals continue to provide all necessary services.
  12. Getting started in the AJRR Registry is easy. For more information about using the AJRR to meet your mandated CJR requirements, visit www.AJRR.net or phone 847-292-0531 to find the Program Coordinator in your area.

For a list of CMS frequently asked questions about CJR, visit https://innovation.cms.gov/Files/x/cjr-faq.pdf

For more information on the AJRR PROMS guide and a list of the full PRO and Risk Variable Data Elements, visit www.AJRR.net