Comments previously submitted by AAOS can be viewed at
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Published 10/1/2017
Elizabeth Fassbender

AAOS Commends CMS for Important Changes to Bundled Payment Models

CMS announces SHFFT cancellation, scaling down of CJR
On Aug. 15, 2017, the Centers for Medicare & Medicaid Services (CMS) announced a proposed rule that addressed significant concerns raised by the American Association of Orthopaedic Surgeons (AAOS) related to mandatory bundled payment programs.

First, the proposed rule would reduce the number of mandatory geographic areas participating in the Center for Medicare and Medicaid Innovation's (Innovation Center) Comprehensive Care for Joint Replacement (CJR) model from 67 to 34. In the other 33 areas, the proposed rule would allow CJR participants to participate on a voluntary basis. According to the proposed rule, CMS selected the 34 Metropolitan Statistical Areas (MSAs) with the highest average wage-adjusted historic lower extremity joint replacements episode payments for continued mandatory participation. In doing so, the agency could evaluate the effects of the CJR model across a wide range of providers, including some that might not otherwise participate in the model. "Higher payment areas are most likely to have significant room for improvement in creating efficiencies and greater variations in practice patterns," CMS wrote.

In all geographic areas, CMS also proposed to make participation in the CJR model voluntary for all low-volume and rural hospitals. A "one-time participation election period" for hospitals with a primary address located in the voluntary participation MSAs and for specified low-volume hospitals and rural hospitals in the mandatory participation MSAs would begin Jan. 1, 2018, and end Jan. 31, 2018.

Finally, CMS proposed cancelling the Surgical Hip and Femur Fracture Treatment (SHFFT) payment model and others that were scheduled to begin Jan. 1, 2018.

AAOS commends CMS for this important proposal and will be submitting comments by the Oct. 16 due date. Previous comments submitted by AAOS on this issue can be viewed at

"AAOS applauds Secretary of Health and Human Services (HHS) Tom Price, MD; CMS Administrator Seema Verma, and others at CMS for clearly hearing concerns of orthopaedic surgeons related to these mandatory payment models," said AAOS President William J. Maloney, MD. "As we have said before, AAOS strongly supports the efforts of all stakeholders to develop payment models that incentivize care coordination and address rising healthcare costs. Additionally, appropriate alternative payment models are a necessary component of the current Quality Payment Program. However, imposing mandatory models on surgeons and facilities that lack the familiarity, experience, or infrastructure required has serious unintended consequences. Reducing the geographic area for CJR while still leaving a voluntary option significantly remedies this issue. We thank CMS for their work on this proposed rule and will be commenting officially with a more detailed response."

"Changing the scope of these models allows CMS to test and evaluate improvements in care processes that will improve quality, reduce costs, and ease burdens on hospitals," said Ms. Verma. "Stakeholders have asked for more input on the design of these models. These changes make this possible and give CMS maximum flexibility to test other episode-based models that will bring about innovation and provide better care for Medicare beneficiaries."

In the proposed rule, CMS explained that, in the future, they expect to increase opportunities for providers to participate in voluntary initiatives rather than large mandatory episode payment model efforts. The changes in the proposed rule, according to CMS, would allow the agency to engage providers in future voluntary efforts, including additional voluntary episode-based payment models. Specifically, CMS noted that the Innovation Center expects to develop new voluntary bundled payment model(s) during CY 2018, building on the Bundled Payments for Care Improvement initiative, that will be designed to meet the criteria to be an Advanced Alternative Payment Model.

"Many providers are currently engaged in voluntary initiatives with CMS, and we expect to continue to offer opportunities for providers to participate in voluntary initiatives, including episode-based payment models," the agency wrote in the proposed rule.

For more information on the CJR Model, visit For more information on the models proposed for rescission, visit

The proposed rule (CMS-5524-P) can be downloaded from the Federal Register at Public comments are due by Oct. 16, 2017, at 11:59 p.m. EST.

Elizabeth Fassbender is the communications manager in the AAOS office of government relations. She can be reached at