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September 15, 2015



Comprehensive Care for Joint Replacement Model

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Comprehensive Care for
Joint Replacement Model

In July, CMS released a proposed rule that would test bundled payment and quality measures for an episode of care associated with hip and knee replacements in 75 geographic areas affecting more than 100,000 Medicare patients (read more in AAOS Now online here). The Comprehensive Care for Joint Replacement model would be the first mandatory Medicare bundled payment program promulgated under CMS’ CMMI authority, and if adopted, would go into effect in January 2016.

“The AAOS supports efforts by CMS to make appropriately structured alternative payment models available to physicians and other providers, including bundled and episode payment models,” stated David D. Teuscher, MD, President of AAOS. “In fact, many AAOS members have been leaders in developing, implementing, and evaluating episode of care payments. However, the AAOS has multiple concerns about the proposed rule and we urge CMS to strongly consider significant changes to the program as proposed.”

AAOS’s primary concerns with the proposal include:
Free webinar!
FREE WEBINAR – Comprehensive Care for Joint Replacement: Understanding the CMS Proposed Mandatory TJR Bundling

Sep 29, 2015
7:15 PM - 8:15 PM Central

Join Craig Robert Mahoney, MD; Alexandra E. Page, MD; Timothy Pysell, DrHA; and Michael Suk, MD, JD, MPH, FACS, for a webinar to discuss the impact the proposed payment model would have on you and your practice.

Register online by clicking here.

Or call AAOS Customer Service at 1-800-626-6726.
  • Mandatory participation of ALL hospitals located in any of the 75 Metropolitan Statistical Areas (MSAs) pre-determined by CMS which, in effect, mandates participation in the program of all surgeons, providers, facilities, and other parties that provide care surrounding lower-extremity joint replacement (LEJR) procedures and do so in any one of the 75 MSAs;
  • The immediate and full implementation of the proposal beginning January 1, 2016;
  • A lack of designated physician leadership for episodes-of-care;
  • The lack of infrastructure support from CMS necessary to properly administer and undertake the proposed changes;
  • The absence of risk-adjustment in the program;
  • Inappropriate conditions included in the proposed episodes-of-care;
  • Inappropriate proposed patient reported outcome tools and risk variables;
  • The retrospective episode payment methodology; and
  • Insufficient patient protections and incentives.

AAOS strongly urged CMS to revise the mandatory nature of the proposal and instead create incentives for interested participants that would reward innovation and high quality patient care.  Specifically, AAOS recommended that CMS require any participating entity have verifiable interoperability, infrastructure, and agreements between all necessary entities.

AAOS also addressed the immediate and full implementation of the program, stating that the 60 days between the deadline for comments on the final rule and implementation is far too brief to properly implement and transition into this model.

“Full scale implementation within 60 days of final rule publication of a mandatory bundled payment model is unrealistic and likely to cause disruption in normal patient access to care patterns, potentially causing financial harm to physicians and facilities,” Dr. Teuscher stated. “A gradual transition from a voluntary to mandatory program would be more realistic and provide ample time for assessing coordination, developing clinical pathways, and executing legal agreements between physician groups and managers of facilities, all factors essential to a successful program.”

Further, AAOS highlighted that a number of additional factors, including ICD-10 and meaningful use barriers, are likely to add to the difficulty in implementing a mandatory model. As stated in the comment letter, providers continue to require better analytics and support, tools for best practices and ease of reporting, validated patient risk assessment measures, and data sharing with physicians through required transparency by hospitals and payers. While CMS has made progress in some of these areas, it still needs to further strengthen the support and infrastructure for physicians and facilities before adding programs that require significant additional infrastructure investment and development.

“The timing of the proposal is further exacerbated by the concurrent mandatory adoption of ICD-10, which will likely demand physician and facility focus over the next several quarters,” wrote Dr. Teuscher. “Infrastructural support is incomplete, meaningful use attestation is at 18 and 48% for physicians and hospitals, respectively, and EHR vendors have plagued practices with a lack of interoperability and errors in the 2014 PQRS program. Until these glitches are addressed and highly reliable systems are in place, no further mandates should be initiated.”