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1 [1] (March 31, 2016)

handle is hein.crs/govcczt0001 and id is 1 raw text is: FF. ' riES- - $r h ,. , Updated March 31, 2016 The Comprehensive Care Joint Replacement Model The Medicare program has been criticized for failing to include policies that financially incentivize health care providers to deliver efficient, high-quality health care. The Patient Protection and Affordable Care Act (P.L. 111-148) added Section 11 15A to the Social Security Act (SSA), authorizing the creation of the Center for Medicare & Medicaid Innovation, the Innovation Center. The Innovation Center is an agency within the Centers for Medicare & Medicaid Services (CMS) that supports the development and testing of alternative payment and service delivery models to promote care coordination, quality, and efficiency of health care services. Examples of alternative payment models under way at the Innovation Center include the Bundled Payment for Care Improvement (BPCI) initiative. The BPCI currently tests different retrospective or prospective episode-based payment initiatives to improve the efficiency of care delivery. For example, one such model allows hospitals and post-acute care providers that choose to participate to enter into gain-sharing agreements-agreements that retrospectively distribute a portion of reduced health care expenditures that fall below a target episode price among parties. However, after a preparation period (Phase I), under the risk-bearing phase (Phase II) participants must also repay a portion of health care expenditures that exceed a target episode price under risk-sharing agreements. Participants may choose the duration of the episode (30 days, 60 days, or 90 days) and the clinical episode that will trigger the bundled episode payment. As of October 13, 2015, roughly 298 acute-care hospitals were participating in the BPCI models that included lower-extremity joint replacement (LEJR) episodes. On November 24, 2015, CMS finalized in the Federal Register a new mandatory episode-based payment model for certain acute-care hospitals. Under CMS's SSA Section 11 15A authority, beginning April 1, 2016, the Innovation Center will test a 90-day retrospective episode-based payment to certain acute-care hospitals for Medicare beneficiaries enrolled in Parts A and B who receive LEJR procedures. This model is being conducted to improve coordination and incentivize higher-value care across the different care settings for a common, high-expenditure medical procedure (i.e., LEJR) with substantial regional variation in care delivery and spending. The model is to include five performance years, beginning April 1, 2016, and ending after December 31, 2020. All providers continue to receive typical Medicare Part A and Part B reimbursements for care provided during the episode. However, under the model, each eligible hospital's Medicare episode spending will be reconciled against a hospital-specific target episode price following a performance year for hospitals in certain geographic areas. Under Section 11 15A of the SSA, the Secretary may expand the duration, scope, and geographic areas included in the model if certain requirements are met. CMS randomly selected metropolitan statistical areas (MSAs) to be included for participation in this Comprehensive Care Joint Replacement (CJR) model. An MSA is composed of a county or counties (or parishes and boroughs) and represents economically and socially integrated populations. Of the 384 total MSAs in the United States, 188 MSAs were ineligible to participate in the CJR model because too few LEJR episodes had been performed by acute-care hospitals within the MSAs over the past few years (not participating in the BPCI) or because more than 50% of LEJR episodes included acute-care hospitals, skilled nursing facilities, or home health agencies participating in the risk-bearing phase-where participants assume financial risk-of the BPCI model. The remaining 196 MSAs were stratified by population, LEJR procedure, and Medicare spending 90 days after discharge over the past three years. CMS randomly selected 67 MSAs using a methodology that proportionally underweighted more efficient MSAs and overweighted more expensive MSAs. All acute-care hospitals located in the 67 MSAs will participate in the CJR model beginning April 1, 2016, unless otherwise excluded. Excluded hospitals include (1) hospitals not reimbursed under Medicare's inpatient prospective payment system and (2) hospitals participating in the BPCI models that include LEJR episodes. According to publically-available information on the Innovation Center website, 798 acute-care hospitals across the 67 MSAs will participate in the CJR model. Under the CJR model, eligible acute-care hospitals located in one of the 67 MSAs will participate in the CJR model and be at financial risk of Medicare spending per beneficiary for LEJR episodes. The episode begins with a hospital inpatient admission for an LEJR procedure, most often a total hip or knee replacement procedure. The episode ends 90 days after the patient is discharged from the hospital following the LEJR procedure. Medicare episode spending will include physicians' services, inpatient hospital services and related hospital readmissions, post-acute care services (i.e., skilled nursing facility and home health services), hospital outpatient services, durable medical equipment, drugs reimbursed under Medicare Part B, and hospice services. The target episode price will be adjusted for LEJR episodes that begin with a hospital inpatient admission for hip fracture. Two-thirds of the target episode price will initially be based on each hospital's average LEJR episode spending over the .O 'T mppm qq\ p\w gn'a', ggmm a 'S I 11LULANJILiN,

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