FACT SHEET
FOR IMMEDIATE RELEASE
November 16,
2015
Contact: CMS Media Relations
(202) 690-6145 | CMS
Media Inquiries
Comprehensive Care for Joint Replacement
(CJR) Model
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.
Yet, the quality and cost of care for these hip and knee replacement
surgeries still varies greatly. For instance, the rate of complications like
infections or implant failures after surgery can be more than three times
higher for procedures performed at some hospitals than others. And the average
total Medicare expenditure for surgery, hospitalization, and recovery ranges
from $16,500 to $33,000 across geographic areas.
This variation is due partly to the way Medicare beneficiaries receive
care. Incentives to coordinate the whole episode of care – from surgery to
recovery – are not strong enough, and a patient’s health may suffer as a
result. When approaching care without seeing the big picture, there is a risk
of missing crucial information or not coordinating across different care
settings. This approach leads to more complications after surgery, higher
readmission rates, protracted rehabilitative care, and variable costs. These
are not the health outcomes patients want.
The Comprehensive Care for Joint Replacement (CJR) model addresses low
quality and high costs that come from fragmentation by promoting coordinated,
patient-centered care. This model aims to improve the care experience for the
many and growing numbers of Medicare beneficiaries who receive joint
replacements, making the patient’s successful surgery and recovery a top
priority for the health care system.
How the CJR model helps—and protects—beneficiaries:
- Patients can benefit
from their hospitals and other health care providers (e.g., physicians,
home health agencies, and nursing facilities) working together more
closely to coordinate their care. Coordination of care leads to better
outcomes, a better experience, and fewer complications, such as
preventable readmissions, infections, or prolonged rehabilitation and
recovery.
- Beneficiaries will
benefit from protections including: additional monitoring of claims data
from participant hospitals to ensure that hospitals continue to provide
all necessary services; continued protection of patient data under the
Health Insurance Portability and Accountability Act of 1996 (HIPAA) and
other applicable privacy laws; and patient notification by providers and
suppliers. Further, all existing safeguards to protect beneficiaries and
patients will remain in place. If a beneficiary believes that his or her
care has been adversely affected, he or she can call 1-800-MEDICARE or
contact his or her state’s Quality Improvement Organization (QIO) by going
to http://www.qioprogram.org/contact-zones.
If concerns are identified, CMS will initiate audits and corrective action
under existing authority.
- Patients can continue to
choose their doctor, hospital, skilled nursing facility, home health
agency, and other provider, but now with the CJR model, their providers
have incentives to better coordinate their care. From surgery to recovery,
patients can receive more comprehensive, coordinated care from their
providers focusing on the most appropriate options for their recovery and
rehabilitative care.
How the CJR Model works:
- CMS has learned from
other models and projects already underway and has incorporated successful
design elements from other initiatives into the CJR model design. The CJR
model also reflects best practices in the private sector.
- Under this model, the
hospital in which the hip or knee replacement and/or other major leg
procedure takes place will be accountable for the costs and quality of
related care from the time of the surgery through 90 days after hospital
discharge—what is called an “episode” of care.
- Depending on the
hospital’s quality and cost performance during the episode, the hospital
will either earn a financial reward or, beginning with the second
performance year, be required to repay Medicare for a portion of the
spending above an established target. This payment structure gives
hospitals an incentive to work with physicians, home health agencies,
skilled nursing facilities, and other providers to make sure beneficiaries
receive the coordinated care they need with the goal of reducing avoidable
hospitalizations and complications. Hospitals in the model will be
provided access to additional tools – such as spending and utilization
data and sharing of best practices -- to improve the effectiveness of care
coordination. The model also gives providers
additional flexibilities that are not otherwise available under Medicare
so they can better manage the care of patients, including patients who are
at home.
- By “bundling” payments
for an episode of care, hospitals, physicians, and other providers have an
incentive to work together to deliver more effective and efficient care.
- This model is being
tested in 67 geographic areas throughout the country, and nearly all
hospitals in those geographic areas are required to participate.
Reasons for the CJR Model:
- Lower extremity joint
replacements are the most commonly performed Medicare inpatient surgery,
and utilization is predicted to continue to grow. These surgeries can
require long recoveries that may include extensive rehabilitation or other
post-acute care, which provides many opportunities to reward providers
that improve patient outcomes.
- By including all
eligible hospitals in 67 geographic areas across the country, this model
drives significant movement towards new payment and care delivery models
for an important set of conditions and surgeries for Medicare
beneficiaries.
- This model supports HHS
efforts to transform the health care system towards one focused on better
quality care, smarter spending, and healthier people through care transformation
and payment reform.
For more information, visit: https://innovation.cms.gov/initiatives/cjr
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