Proposed Medicare Changes: Excluding Certain Procedures Could Derail CJR Success

By a News Reporter-Staff News Editor at Insurance Weekly News -- The Centers for Medicare and Medicaid Services (CMS) just released the 2018 Outpatient Prospective Payment System (OPPS) proposed rule. A key issue within may fundamentally alter the way the Comprehensive Care for Joint Replacement (CJR) bundled payment model functions.

The proposed OPPS rule removes outpatient knee replacement procedures from the inpatient-only list, allowing providers to perform knee replacements in an outpatient setting and, in turn, remove those patients from the CJR program. This new rule shifts the target away from CMS' initial assessment, and means participants with a significant amount of knee replacement patients in their CJR program will be disadvantaged.

DataGen, an analytics and modeling organization focused on the financial implications of health payment reform, has issued commentary to its client organizations, alerting them to this new proposed rule and its potentially damaging consequences. "This change effectively alters the rules in the middle of the game," said Darcie Hurteau, DataGen's Director of Informatics.

Hurteau adds, "CMS uses three years of historical data to set 90-day episode payment targets for each participant in the CJR program. The less complex, lower-cost patients were included when CMS established their historical baseline data. This means the targets CMS will use for the remaining more complex patients (i.e., more expensive 90-day bundle) will be based on a different mix of patients than the patients who will remain in the program."

While the current proposed rule focuses on knee replacements, CMS is seeking additional comment on whether partial and total hip arthroplasty should also be removed from the inpatient-only list and added to the Ambulatory Surgical Center-covered procedure list.

Hurteau further explained, "The remedy for this proposed change will be difficult. Ideally, CMS should recalculate the target to reflect the patient mix that will exist after patients migrate to outpatient settings, but identifying those patients retroactively in the baseline data will be difficult. There aren't universal, specific criteria applied by surgeons in selecting the setting for their surgeries."

Hurteau recommends that participants evaluate their data to understand the effect of this proposed rule and monitor any changes CMS proposes to the target setting process moving forward. Providers who oppose this proposed rule should submit comment on the negative impact to CMS by September 11th and reach out to their professional associations.

Keywords for this news article include: Biotechnology, Biomedical Engineering, Biomedicine, DataGen, Medicare, Health Policy, Bioengineering, Medical Devices, Knee Replacement.

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