The Centers for Medicare & Medicaid Services (CMS) is proposing a nationwide expansion of the Comprehensive Care for Joint Replacement (CJR) model, with the goal of driving more coordinated care for people receiving hip, ankle and knee replacements – including through skilled nursing facility services.
This proposed expansion would build on the original CJR model, which concluded on Dec. 31, 2024.
“The most recent evaluation of performance years 6 and 7 (2021-2023) showed that the CJR Model generated an estimated $112.7 million in net Medicare savings while maintaining quality for over 98,000 knee and hip replacement patients across 323 hospitals,” CMS stated in its April 10 announcement of the expanded CJR model, dubbed CJR-X.
Skilled nursing facility operators are likely to view the return of CJR with trepidation. In the first iteration of the program, much of the Medicare savings came at the expense of SNFs, as the model rewarded care delivered in lower cost settings.
Given that the model will incentivize hospitals and post-acute providers to deliver cost-effective care, some Medicare rules might be waived under CJR-X. The 3-day stay requirement – involving a qualifying 3-day hospital inpatient stay for Medicare coverage of ensuing SNF care – is one program rule that could be waived, CMS stated in its proposal.
CJR-X would be the first episode-based payment model in original Medicare that would be mandatory for hospitals on a nationwide basis. CMS has proposed a start date of Oct. 1, 2027. Certain hospitals – including those participating in the Transforming Episode Accountability Model (TEAM) – would be initially exempt from CJR-X.
“In the CJR-X Model, participating hospitals would be responsible for ensuring patients receive high-quality, coordinated, affordable care from the time of their procedure through the first 90 days of recovery, which incentivizes hospitals to help patients navigate all aspects of care, including physical therapy and other outpatient or at-home rehabilitation,” CMS stated.
In CJR-X, hospitals would be assessed against a target price for all costs associated with the joint replacement procedure and post-surgery care. At the end of a performance year, actual spending for care episodes will be compared against a hospital’s target price, and hospitals will be eligible for additional Medicare payments or might have to repay a portion of the payments incurred in the episode.
CMS is proposing certain guardrails, such as a 5% stop loss for hospitals with large dual-eligible populations and a “robust risk adjustment methodology” that includes 29 adjusters. That’s compared to just 3 adjusters in the original CJR model.
Hospitals also would have to achieve a minimum level of quality before receiving reconciliation payments.
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