More Bundled Payments on the Way – CJR


As expected, the Centers for Medicare & Medicaid Services (CMS) recently laid out its proposal for escalating use of bundled payments beyond total hip and knee arthroscopy (joint replacements). The plan introduces mandatory episode payment models for acute myocardial infarction (AMI, or heart attack) treated with or without percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG) and surgical hip/femur fracture treatment (SHFFT). The latter effectively expands the scope of the agency’s Comprehensive Care for Joint Replacement (CJR) initiative, launched earlier this year, to include patients that have femur repairs without hip replacement.

The new payment models impact 98 randomly selected markets (excluding rural hospitals) and look remarkably similar to the first mandatory bundled payment experiment newly underway:

  • All related care within 90 days of hospital discharge will be included in an episode
  • Acute care hospitals will be the episode initiators and bear the financial risk
  • The program will have five performance years, beginning July 1, 2017
  • CMS will continue to reimburse providers on a fee-for-service basis but then “adjust” that payment at the end of each performance year based on a target price and composite quality score (repayments won’t be required until year two)
  • Adjustments can be positive (reconciliation payment) or negative (repayment) for affected hospitals, although repayments won’t be required until year two
  • For SHFFT, impacted markets include all current CJR regions and quality measures will be the same as for CJR – risk-standardized complication rate following total hip or total knee replacement, HCAPHS scores and successful voluntary reporting of patient-reported outcomes

For AMI, the quality measures being proposed by CMS include risk-standardized mortality rate at 30 days post-discharge, excess days in acute care (includes emergency department, observation and inpatient readmission days) and HCAPHS scores. The mortality and HCAPHS measures apply to CABG procedures.

A new twist on this go-round is that CMS is also proposing to make incentive payments to bundled hospitals in 90 of the targeted regions—as well as some fee-for-service hospitals to be determined—to provide AMI or CABG patients with greater care coordination and intensive cardiac rehabilitation services for 90 days post-discharge, to test the impact on quality of care and Medicare spending.

This will be a two-part incentive payment, paid retrospectively based on total cardiac rehabilitation use of beneficiaries being treated at participating hospitals. The payment amount will be $25 for each of the first 11 visits and after that would increase to $175 per service paid and approved by Medicare during the care period for a heart attack or bypass surgery. Based on Medicare coverage, patients can receive a maximum of two, one-hour sessions per day—up to 36 sessions over 36 weeks, with the option of adding another 36 sessions if approved by their Medicare Administrative Contractor. Intensive cardiac rehabilitation program sessions would be limited to 72, one-hour sessions (up to six per day) over a period of no more than 18 weeks.

Successfully managing entire episodes of care requires improved coordination of care between providers, but also a focus on care redesign to reduce complications, increase efficiency and drive better outcomes. Click here to learn more about these new bundled care programs or how HealthTrust’s InSight Advisory services can help.

Author Information

April Simon

April Simon

April Simon, RN, MSN, is an assistant vice president at HealthTrust and leads its Clinical Data & Analytics programs. She has over 20 years of hospital-based cardiac, nursing and administrative experience with cardiac programs. Simon’s expertise has led to consultations with manufacturers conducting clinical trials as well as hospitals and health systems seeking to implement best practices to improve operations and patient outcomes. She works with the American College of Cardiology and the Accreditation for Cardiovascular Excellence, has contributed to numerous publications and was one of the first Certified Critical Care RNs whose practice was based in a cath lab. More Articles by This Author »

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