Tuesday’s proposal by the Centers for Medicare and Medicaid Services (CMS) would scale back the Comprehensive Center for Joint Replacement (CJR) mandatory bundles for lower extremity joint replacement and would eliminate the mandatory episode payment models (EPMs) for surgical hip/femur fracture episodes of care (SHFFT).

CMS stated:

Many providers are currently engaged in voluntary initiatives with CMS, and we expect to continue to offer opportunities for providers to participate in voluntary initiatives, including episode-based payment models. We are concerned that engaging in large mandatory episode payment model efforts at this time may impede our ability to engage providers, such as hospitals, in future voluntary efforts.

The Future of CJR
The proposal would cut in half the number of regions subject to mandatory participation in the CJR bundled payment initiative for lower extremity joint replacements (hospitals already participating in the voluntary BPCI program are exempt).  However, the Texas markets would remain in place under the proposed rule.

The End of the EPM Model
Last year, CMS introduced the new SHFFT model that would pay for surgical hip/femur services through episodes of care (a shift away from fee-for-service payments) in numerous markets.  The Trump administration has continued to delay the 2017 start date, and January 1, 2018 is the current start date.  However, this proposed rule would completely eliminate this model.

New Bundled Payment Initiatives in the Future?
TOA has been indicating over the past year that CMS is likely to introduce new voluntary, physician-led bundled payments in the future that would help surgeons meet the Alternative Payment Model (APM) requirements under MACRA.

CMS stated the following in this proposed rule:
“Building on the BPCI initiative, the Innovation Center expects to develop new voluntary bundled payment model(s) during CY 2018 that would be designed to meet the criteria to be an advanced APM.”

Technical Issues with CJR
The proposed rule also included several technical additions to CJR.  Much of it focuses on telehealth services related to lower extremity joint replacement surgery.

Clinical Engagement Lists for APMs
The proposed rule provides commentary on clinical financial arrangement lists related to APMs.

The following commentary is provided by CMS:

Stakeholders have expressed a desire for model changes that would also include in the clinician financial arrangement list physicians, non-physician practitioners, and therapists without a financial arrangement under the CJR model, but who are affiliated with and support the Advanced APM Entity in its participation in the Advanced APM for purposes of the Quality Payment Program.

We agree with stakeholders that these physicians, non-physician practitioners, and therapists should have their contributions to the Advanced APM Entity’s participation in the Advanced APM recognized under the Quality Payment Program; however, since these individuals do not have financial arrangements with the participant hospital, to also include them on the clinician financial arrangement list would be misleading, and could create confusion when CJR model participant hospitals submit lists to CMS.

To increase opportunities for eligible clinicians supporting CJR model participant hospitals by performing CJR model activities and who are affiliated with participant hospitals to be considered QPs, we are proposing that each physician, non-physician practitioner, or therapist who is not a CJR collaborator during the period of the CJR model performance year specified by CMS, but who does have a contractual relationship with the participant hospital based at least in part on supporting the participant hospital’s CMS-5524-P 51 quality or cost goals under the CJR model during the period of the performance year specified by CMS, would be added to a clinician engagement list.

In addition to the clinician financial arrangement list that is considered an Affiliated Practitioner List for purposes of the Quality Payment Program, we propose the clinician engagement list would also be considered an Affiliated Practitioner List. The clinician engagement list and the clinician financial arrangement list would be considered together an Affiliated Practitioner List and would be used by CMS to identify eligible clinicians for whom we would make a QP determination based on services furnished through the Advanced APM track of the CJR model.

This proposal would broaden the scope of eligible clinicians that are considered Affiliated Practitioners under the CJR model to include those without a financial arrangement under the CJR model but who are either directly employed by or contractually engaged with a participant hospital to perform clinical work for the participant hospital when that clinical work, at least in part, supports the cost and quality goals of the CJR model.