By using this site, you agree to the Privacy Policy and Terms of Use.
Accept
Health Works CollectiveHealth Works CollectiveHealth Works Collective
  • Health
    • Mental Health
    Health
    Healthcare organizations are operating on slimmer profit margins than ever. One report in August showed that they are even lower than the beginning of the…
    Show More
    Top News
    physical health
    5 Ways Playing Games Can Improve Neural and Physical Health
    September 9, 2022
    Reasons For Hair Loss and Its Treatment
    Reasons For Hair Loss and Its Treatment
    February 16, 2022
    healthcare organization
    5 Actionable Strategies For Healthcare Organizations
    August 15, 2022
    Latest News
    Why Custom Telemedicine Apps Outperform Off‑the‑Shelf Solutions
    July 20, 2025
    How Probate Planning Shapes the Future of Your Estate and Family Care
    July 17, 2025
    Beyond Nutrition: Everyday Foods That Support Whole-Body Health
    June 15, 2025
    The Wide-Ranging Benefits of Magnesium Supplements
    June 11, 2025
  • Policy and Law
    • Global Healthcare
    • Medical Ethics
    Policy and Law
    Get the latest updates about Insurance policies and Laws in the Healthcare industry for different geographical locations.
    Show More
    Top News
    health insurance rate shock
    Subsidies Will Temper Health Insurance “Rate Shock” for the Young
    June 8, 2013
    Future Diabetes Treatment Approaches
    September 12, 2011
    Image
    Delaying the “Employer Mandate”
    July 5, 2013
    Latest News
    How IT and Marketing Teams Can Collaborate to Protect Patient Trust
    July 17, 2025
    How Health Choices and Legal Actions Intersect After an Injury
    July 17, 2025
    How communities and healthcare providers can address slip and fall injuries with legal awareness
    July 17, 2025
    Let Your Lawyer Handle the Work Before You Pay Medical Costs
    July 6, 2025
  • Medical Innovations
  • News
  • Wellness
  • Tech
Search
© 2023 HealthWorks Collective. All Rights Reserved.
Reading: The ABCs of CCJR
Share
Notification Show More
Font ResizerAa
Health Works CollectiveHealth Works Collective
Font ResizerAa
Search
Follow US
  • About
  • Contact
  • Privacy
© 2023 HealthWorks Collective. All Rights Reserved.
Health Works Collective > Policy & Law > Health Reform > The ABCs of CCJR
Health ReformPolicy & LawPublic Health

The ABCs of CCJR

wellbeme
wellbeme
Share
7 Min Read
SHARE

The recent announcement by CMS of its proposed Comprehensive Care for Joint Replacement (CCJR) program is raising more than a few eyebrows.  This mandated orthopedic bundle program is scheduled to begin January 1, 2016 for hospitals in specified geographic areas.  CMS expects to save $153M with CCJR as part of moving 50% of Medicare Fee-for-Service (FFS) to value-based care by 2018.

The recent announcement by CMS of its proposed Comprehensive Care for Joint Replacement (CCJR) program is raising more than a few eyebrows.  This mandated orthopedic bundle program is scheduled to begin January 1, 2016 for hospitals in specified geographic areas.  CMS expects to save $153M with CCJR as part of moving 50% of Medicare Fee-for-Service (FFS) to value-based care by 2018.

While the final rule has yet to be written (public comment is due by September 8, 2015), the outline of the program has been established.  Spanning about 450 pages, there’s plenty to decode in the voluminous proposed rule.  So here’s a quick “cheat sheet” to get you up to speed.

By the way, if your hospital is targeted for this program, you should begin work the moment you finish reading this as there’s no time to waste.

More Read

TDWI’s Kevin Campbell Discusses Aspirin and Tylenol
Tell Your Story: 2013 Costs of Care Essay Contest Is Open!
Mobile Health Around the Globe: Treating Malnutrition in Zanzibar
Top Three Essentials for General Health Care during Pregnancy
How to Control Healthcare Costs: Lessons from Singapore

A mandated program?

  • The program is mandatory for hospitals in 75 markets (called MSAs). See http://innovation.cms.gov/initiatives/ccjr/ for a list of those MSAs.
  • There’s no application process.
  • CCJR is heavily based on the Bundled Payment for Care Improvement (BPCI) Model 2 program.
  • Only hospitals can be episode initiators – other entities such as group practices or skilled nursing facilities are excluded.
  • There are no conveners in this model.
  • CCJR includes DRGs 469 and 470.
  • The program begins Jan 1, 2016 and continues for 5 years.
  • You are at risk beginning Jan 1, 2017 (there is only upside during 2016).
  • You must meet quality measures to be eligible for gains.
  • Gainsharing with other provides is allowed within program guidelines.
  • Price targets are partially regional-based (100% regional-based in years 4 and 5) and updated annually.

But what else?

  • Medicare takes 2% off the top of the TOTAL program.
  • That means you need to drive total spend down by 2% to break even.
  • Moreover, since the DRG portion is about 25% of the bundle spend, you need to drive post-acute spend down by 8% just to break even.
  • CMS is proposing to grant these waivers:
    • “Incident to” rule for home health allows post-discharge home visits where they were previously not allowed.
    • Telehealth services are allowed in “all” geographies.
    • SNF 3-day in years 2-5 of the program.
  • But there are not waivers (yet) for issues such as anti-kickback, CMP, self-referral, etc. CMS is expecting that those will be address later by rulings from the OIG, for example.

Can you tell me more?

  • The program only applies to Medicare FFS primary beneficiaries (with other minor exclusions).
  • There are program exclusions such as unrelated readmissions and certain Part B services.
  • Continue billing FFS with retrospective annual reconciliations to determine gains/losses.
  • The initial target priced is based on claims performance from 1-1-12 thru 12-31-14 and remains the target price for the 1st 2 years. In subsequent years, the baseline of the target price is shifted forward by a year.
  • The target has a component based on all hospitals in a defined census region while program selection is based on a different geographic definition – the MSA.
  • For reference, CMS indicates that for CCJR, 55% of spend is inpatient, 25% is post-acute, and 20% is physician.
  • Stop-loss and stop-gain limits protect you against big losses in exchange for limits on gains.
    • CMS estimates that a small number of hospitals will be affected by the stop-loss and almost no hospitals will be affected by the stop-gains.
  • You must meet specific quality measures to be eligible for gains:
    • Those metrics are readmissions, complication rates, and HCAHPS (same as Hospital Compare).
    • You will need to score above 30th percentile in years 1-3 and above the 40th percentile in years 4-5.
  • Voluntary reporting of patient-reported outcomes (at least 80% of patients) results in lower % withheld. (i.e. more potential upside for you)
  • Claims data is available on request (quarterly). Target prices will be provided as well as aggregate regional data and baseline data used to calculate target prices.
  • Patients can opt out of sharing claims data.
  • There are adjustments/accommodations if you’re in other CMS value-based programs.

What should I be doing NOW?

First, determine if you are in one the 75 MSAs.  If you are, you’re in the program and need to begin work now – see the following items.

  • Assess your organization’s readiness for this model. There’s a lot more to this than meets the eye.
  • Evaluate where your opportunities are using data analytics and other sources (hint: almost everything’s in post-acute).
  • Determine the effect of care process reengineering to address quality and spend (they go hand-in-hand).
  • Establish necessary policies re: care transitions, evidence-based decision making, etc. that will drive savings in the post-acute timeframe.

Of course, there’s a lot to do and getting started is the key.  Keep in mind that performance targets are based on how you compare to other hospitals in your area (unlike BPCI where you’re only compare to your own historical performance).  If other hospitals in your region get out ahead of you, you’ll always be playing catch-up and might even find yourself in perpetual no-win (i.e., losing money in this service line) situation.

About the Author:
Sheldon Hamburger serves as a Principal of The Aristone Group, a Raleigh, NC based healthcare consulting group. With over 30 years of experience in developing and marketing healthcare technology products and services, Mr. Hamburger’s career includes various “firsts” in medical and pharmaceutical financial processing systems including electronic claims and payment applications. He earned a bachelor’s degree in Computer Engineering from the University of Michigan.

The post The ABCs of CCJR appeared first on OrthoServiceLine.com.

Share This Article
Facebook Copy Link Print
Share

Stay Connected

1.5kFollowersLike
4.5kFollowersFollow
2.8kFollowersPin
136kSubscribersSubscribe

Latest News

botox certification
Help Improve People’s Skin Health Via Botox Certification
Skin Specialties
July 22, 2025
Telemedicine Apps
Why Custom Telemedicine Apps Outperform Off‑the‑Shelf Solutions
Health
July 20, 2025
Grounded Healing: A Natural Ally for Sustainable Healthcare Systems
How IT and Marketing Teams Can Collaborate to Protect Patient Trust
Global Healthcare Policy & Law
July 17, 2025
paramedics in surgical gloves and masks
How Health Choices and Legal Actions Intersect After an Injury
Health care
July 16, 2025

You Might also Like

Health Care Reform to be Top of Mind in 2012

December 21, 2011

How Reframing a Problem Can Help Fix HealthCare: Patient Self-Management

January 12, 2012

The Sleepy American

April 11, 2011
Health careMedical InnovationsPublic Health

The Right Time to Find a New Doctor

April 15, 2019
Subscribe
Subscribe to our newsletter to get our newest articles instantly!
Follow US
© 2008-2025 HealthWorks Collective. All Rights Reserved.
  • About
  • Contact
  • Privacy
Welcome Back!

Sign in to your account

Username or Email Address
Password

Lost your password?