Providers in Harrisburg, Pa., Cincinnati, Ohio, Gainesville, Fla. And Lubbock, Tex., may not be applauding a new CMS final rule that scales back Medicare’s Comprehensive Care for Joint Replacement (CJR) program next year. That’s because in those localities – as well as 30 other high-cost areas - the CJR program continues to be mandatory next year.
Rural and low-volume hospitals would also be exempted from CJR, though they may voluntarily participate if they wish. Providers in the now non-exempt 33 localities may also voluntarily participate.
However, at urban, high-volume facilities in 34 localities, elective hip and knee replacement procedures will be subject to the mandatory bundled payment model. The payment bundle includes all expenses related to the surgeries, including post-acute care and care of complications.
Bundled payments for joint replacements will vary by locality. In the 34 areas where the program is mandatory, payments will range from $27,000 to $33,000 per case. If a facility can deliver care for less than the target amount — and meet certain quality reporting requirements — it may qualify for an incentive payment. However, if a facility exceeds the target amount, it must pay the additional sum back to Medicare.
CMS decided to maintain the CJR mandatory program “so that we may better understand how providers who typically do not participate in voluntary models respond to an episode payment structure,” the agency stated in the final rule. That is: CMS is expecting to make back some money when providers fail to comply with the program. You have been warned.