Advocacy News

March 15, 2016



Annual Meeting Symposium: Payment Models in Orthopaedics

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Annual Meeting Symposium: Payment Models in Orthopaedics
CJR Program Starting April 1

With the Comprehensive Care for Joint Replacement (CJR) program set to start April 1, 2016, a 2016 Annual Meeting symposium on “Bundled and Emerging Payment Models in Orthopaedics” provided a unique opportunity to evaluate current programs and discuss impending changes in reimbursement. At the Orlando meeting, the American Academy of Orthopaedic Surgeons (AAOS) immediate Past-President David Teuscher, MD, gave an overview of the issues involved and Kevin Bozic, MD, MBA, moderated a panel of speakers that touched on everything from keys to success to staying out of trouble with gainsharing.

Mark Froimson, MD, discussed both the successes and difficulties with the Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) program. CMS initiated the program in 2011 with four models of bundled payments. In 2015, the agency announced that over 2,100 acute care hospitals, skilled nursing facilities, physician group practices, long-term care hospitals, inpatient rehabilitation facilities, and home health agencies transitioned from “a preparatory period to a risk-bearing implementation period.” According to Dr. Froimson, these kinds of alternative payment models (APMs) can be friendly to physicians if they know how to use them. He highlighted a recent CMS announcement that an estimated 30 percent of Medicare payments are now tied to alternative payment models that reward quality of care over quantity of services provided to beneficiaries. This movement is in part a result of goals set by the Department of Health and Human Services (HHS) in January 2015, and as such, Dr. Froimson commented that it “behooves us to get on board.” HHS has stated they are looking to have 50 percent of all Medicare fee-for-service payments made via APMs by 2018 (read more in an earlier Advocacy Now article here).

Dr. Froimson then overviewed the CJR program, which bundles payment and quality measures for hip and knee replacements at hospitals in 67 geographic areas, commenting that the CJR program is different because it is mandatory and hospitals alone are the initiators. Included in the model are all lower extremity joint arthroplasty procedures within DRGs 469 and 470. These include elective hip and knee arthroplasty procedures (total or partial) caused by osteoarthritis or similar conditions, but also include ankle arthroplasty, as well as arthroplasty for fracture repair such as hip hemiarthroplasty or total hip arthroplasty for hip fracture. While there is no downside risk the first year, there are stop-loss limits of five percent in performance year two, ten percent in year three, and 20 percent in years four and five. Further, payments are tied to quality, including patient reported outcomes, and gainsharing is available in situations where the participant hospital arranges to engage in care redesign strategies and services with physicians and other CJR collaborators.

On the topic of gainsharing, Anita Pramoda, co-founder of an online venture that coordinates health care services for senior citizens, urged physicians to first get great lawyers, and then ensure transparency. Ms. Pramoda was formerly the Chief Financial Officer at Epic Systems Corporation from 2009 to January 2012. She also suggested that capitol, information technology, and expertise on things outside the operating room are necessary to ensure success. Finally, Michael Suk, MD, discussed the role of orthopaedics in population health management and encouraged physicians to think about what happens next, what direction we are headed in, and where orthopaedics fits in.

Given the CJR implementation, AAOS has commented to CMS that while orthopaedic surgeons have been leaders in developing, implementing, and evaluating episode of care payments, further refinement of the CJR program – including addressing risk-adjustment and designated physician leadership – may be required. AAOS commented on the CJR program in November, with Dr. Teuscher stating that “the AAOS supports efforts by CMS to make appropriately structured alternative payment models available to physicians and other providers, [but] we are very concerned about serious unintended consequences for Medicare beneficiaries and physicians.”

For more information on the CJR program and other Medicare payment issues, visit the AAOS website at