Executive Summary: Hospital episode initiators: Change in mandatory MSAs:

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1 On November 16, 2015, the Centers for Medicare and Medicare Services (CMS) released the final rule for the Comprehensive Care for Joint Replacement (CJR) model, which creates a mandatory lower extremity joint replacement (LEJR) program for hospitals in 67 MSAs. The program begins on April 1, 2016, and will last five years through the end of The provisions of the final rule reflect CMS intent to test and evaluate the impact of bundled payment for LEJR on cost and quality, with the recognition that the full potential of new payment models will require the engagement of an even broader set of providers than have participated to date. This document contains an inclusive table summary of the CJR program rules. Executive Summary: Key issues areas are outlined below: 1. Hospital episode initiators: Hospitals are the only episode initiators and awardees under CJR. 2. Change in mandatory MSAs: CMS expanded their MSA exclusion criteria, and, as a result, 8 MSAs were removed from the list of previously selected 75 MSAs. Going forward, hospitals in only 67 MSAs will be required to participate in CJR. 3. Target prices are created from a blend of hospital-specific and regional historical data: Hospital s target prices will be set using a blend of historical hospital-specific data and regional data: the regional component increases from one-third in years 1 and 2, to two-thirds in years 3, and finally, to 100% in years 4 and 5. If a hospital has less than 20 CJR cases in a single year, the target price will be 100% based on regional data. Census regions will serve as the geographic component of regional pricing. 4. Target prices stratified by patient fracture status: In recognition of the disproportionately high care costs associated with fracture patients when compared to elective joint replacement patients, CMS elected to risk stratify the target price for eac h MS- DRG-anchored episode based on a beneficiary s hip fracture status. 5. Rolling 3-year baseline period: The baseline period will be updated every other year. Target prices for years 1 and 2 would be based on data from CY ; target prices for years 3 and 4 would be based on data from CY , and target prices for year 5 would be based on data from CY 2016 CY Target prices for years 3 5 (which include at least 1 CJR performance year) would not include CJR savings or repayments from earlier performance years. 6. Downside risk will be phased in: CMS finalized policies that would offer providers an on-ramp to downside risk. In year 1, the program will not include any downside risk. CMS applies a discount factor to historical expenditures when calculating target prices. The discount factor varies by the performance year and a hospital s quality performance. Hospitals target prices will be subject to a lower discount factor for the purposes of calculating losses in years 2 and 3. Finally, CMS finalized stop-loss provision. 7. Data access: Hospital participants must request beneficiary claims-level and aggregate data from CMS prior to the start of CJR. Three-year baseline data and current data will be provided to participants prior to April 1, 2016, and on no less than a quarterly basis thereafter. Beneficiaries cannot opt-out of having their data shared with participant hospitals. 8. Gainsharing: OIG waived certain fraud and abuse laws to allow CJR participants to gainshare Medicare savings or internal cost savings with other providers. Gainsharing payments to physicians and PGPs are capped at 50% of a provider s Medicare Part B 1

2 billings attributed to CJR beneficiaries in a given year. CMS granted hospitals the explicit right to share downside risk with providers. This downside risk would be capped at 50% of total Medicare losses. 9. Quality requirements: CMS adopted a composite quality score methodology to link quality and payment. Hospital performance will be measured on 3 metrics: 1) Hospital-level RSCR following elective primary THA and/or TKA (NQF #1550); 2) HCAHPS Survey measure; and 3) voluntary patient reported outcomes (PRO) measure. Hospitals must clear a threshold score to be eligible to receive reconciliation payments. Hospitals with higher composite scores are eligible to receive a higher portion of savings through the application of lower discount factors. 10. BPCI overlap: BPCI episodes take precedence over CJR episodes. While BPCI LEJR participants are not required to participate in CJR for the duration of BPCI, these participants would be required to participant in CJR following the conclusion of their BPCI LEJR performance period if they are located in one of the designated MSAs. Regardless of when they enter CJR, former BPCI LEJR participants would be subject to the pricing rules of the current CJR program year. CJR Program Table The table on the following page illustrates the changes adopted between the proposed and final rules. If the far right column lists no change, this indicates that CMS finalized its initial proposal without modification. 2

3 Provisions of the Proposed Rule Proposed Definition of the Episode Initiator and Selected Geographic Areas Episode Initiators Financial Responsibility for the Episode of Care Overlap with BPCI Geographic Unit of Selection and Exclusion of Selected Hospitals Proposed Rule Acute care hospitals are the only Episode Initiators. Maryland hospitals are excluded from participation. Payments to Maryland hospitals are excluded from regional calculations. Acute care hospitals are the Awardees. There is no Awardee Convener role that may take on risk for providers. Hospitals can explore risk-sharing opportunities with non-providers and join convener groups within the confines of existing law. BPCI Awardees at-risk with LEJR are excluded from CJR while live in BPCI. BPCI Awardees enter CJR when BPCI performance period ends if they are located in one of the 67 selected MSAs. BPCI Awardees that are not at risk for LEJR are required to participate in CJR if located in one of the 67 selected MSAs. BPCI LEJR episodes take precedence over CJR episodes. Will include all hospitals in geographic region (MSA) to prevent cost shifting/patient steering. CMS used stratified random sampling to select geographic regions for inclusion in CJR. Final Rule 3

4 Exclusion of Certain MSAs Proposed Selection Strata Method of Selecting MSAs Episode Definition for CJR Bundle Clinical Dimension of Episodes of Care Beneficiary Inclusion Criteria MSA excluded if: 1) Fewer than 400 LEJR episodes July 1, June 30, 2014; 2) Fewer than 400 non- BPCI LEJR episodes in a year; 3) 50% or more of LEJR episodes initiated by Model 1, 2 or 4 hospital Awardee or Model 3 SNF/HHA Awardee (notice exclusion of PGP Awardees); and 4) 50% of LEJR episodes not paid under IPPS. CMS stratified MSAs by 1) MSA average wageadjusted historic LEJR episode payments; and 2) MSA population size. Chose a methodology that proportionally underweighted more efficient MSAs and over-weighted more expensive MSAs. See rule for specific details. If methodology changes, final selected MSAs could also change. Episode triggered by index admissions for DRGs 469 and 470. Episode includes all Part A and B services (including hospice) during index stay and 90 days post-discharge with exception of services on the current BPCI LEJR Model 2 exclusions list. Note exclusion of Chemotherapy ICD-9 codes, hemophilia clotting factors and technology add-on payments. Eligible beneficiaries must: 1) Have Parts A and B; 2) Not have ESRD; 3) Not be on managed care plan; 4) Not be covered under United Mine Workers of America; and 5) Have Medicare as the primary payor. 4 CMS changed the selection process to reflect the exclusion of BPCI LEJR participants that entered the risk phase in October 2015 as well as BPCI LEJR episodes initiated by PGP participants. As a result, 8 previously selected MSAs were excluded, bringing the total number of selected MSAs to 67. CMS rejected requests to apply additional hospital-specific exclusions (such as low-volume thresholds) within a selected MSA.

5 Dropping Episodes Episode Duration Methodology for Setting Episode Prices and Payment Performance Period Retrospective Payment Methodology Two-sided Risk Model CJR episode is dropped if: 1) Beneficiary readmitted and discharged w/ DRG 469 or 470 during existing episode; 2) Beneficiary dies during an anchor hospitalization; or 3) Beneficiary initiates BPCI LEJR episode. Episode ends 90 days post-discharge from index hospitalization. 5 years beginning Jan. 1, Year 1 includes episodes that start on/after Jan. 1, 2016 and end on/before Dec. 31, Year 2 includes episodes that end between Jan. 1, 2017 and Dec. 31, And so on for years 3-5. Episode payments will be retrospectively reconciled against the target price following completion of each performance year. Upside only in year 1. Upside and downside in years 2-5. Phase in downside responsibility across year 2. CMS changed the proposed rule to eliminate episodes if the patient dies at ANY time during the entire episode, not just during the anchor hospital stay. Thus, CJR episode is dropped if: 1) Beneficiary readmitted and discharged w/ DRG 469 or 470 during existing episode; 2) Beneficiary dies during episode; or 3) Beneficiary initiates BPCI LEJR episode. 5 years beginning April 1, Year 1 includes episodes that start on/after April 1, 2016 and end on/before Dec. 31, Year 2 includes episodes that end between Jan. 1, 2017 and Dec. 31, And so on for years

6 Adjustments to Payments Included in Episode Episode Price Setting Methodology Target prices will not include Medicare repayments or reconciliation payments. Exclude special Medicare payment provisions (DSH, IME, P4P) from target price and performance period spending calculations and account for sequestration. No comment on treatment of non-participating physician claims in target price and aggregate performance period payment amount. Pro-rate payments across beginning and end of episode. Episode payments are capped at 2 standard deviations above the regional mean. Amounts above the cap will not be attributed to the hospital's performance period payments during reconciliation. DRG-specific target prices (no further risk adjustment). 3 years of baseline data. Will be updated/rebased every other year. Performance years 1 and 2 target prices will be based on claims data from CY 12-14; years 3 and 4 use CY 14-16; year 5 uses CY Trend years 1 and 2 of baseline period to year 3 using national trend factor. CMS may revisit this issue in future rulemaking. Claims from both participating and nonparticipating physicians would be included in target price and actual episode spending calculations. CMS will now risk-stratify both DRGs to create a target price for each MS-DRG-anchored episode based on a beneficiary's hip fracture status. CMS will identify hip fractures using the ICD-9/ICD-10 diagnosis codes, where the hip fracture diagnosis is the principal diagnosis on the anchor hospitalization for an LEJR. 6

7 Episode Price Setting Methodology Geographic Regions Used for Regional Component of Pricing Accounting for Variations Due to Wage Index Prospectively-set trend factor used to establish separate target prices for episodes that start between Jan. 1 and Sept. 30 vs. those that start between Oct. 1 and Dec. 31 to account for timing of payment rate updates. Update factors will be hospital-specific; factors weighted based on percent of Medicare payment IPPS, physician, IRF, SNF, HHA, other services accounted for in hospital's historical episodes. Region-specific update factors also used. They do not plan to apply an adjustment to account for changes in national utilization patterns. Calculate target price through blend of hospital-specific and regional (U.S. Census division) historical data. Years 1 & 2 = 2/3 hospital-specific & 1/3 regional. Year 3 = 1/3 hospital-specific & 2/3 regional. Years 4 & 5 = 100% regional. Exception: Hospitals with < 20 CJR episodes during baseline use 100% regional for all 5 years. Additional exceptions for hospitals with new CCNs. Region definition is the 9 U.S. Census divisions. Normalize for wage index differences in historical episode payments when calculating and blending the regional and hospital-specific components of blended target prices. They are modifying calculation methodology for update factors to more accurately capture payment system rate changes throughout the CY for inpatient acute, IRF, and SNF services. CMS will include BPCI Model 1, 2, and 4 participating hospitals when calculating the regional component of CJR target prices. CMS will rename "CJR eligible hospitals" to be "CJR regional hospitals". MSAs that span US Census divisions will be attributed to one US Census division for purposes of calculating the regional component of CJR target prices. CMS will now normalize for wage indices at the claim level for both historical episode expenditures and actual episode expenditures in each performance year by using the wage index normalization algorithm included in the CMS Price (Payment) Standardization Detailed Methodology 7

8 Combination of CJR Episodes Anchored by MS-DRGs 469 and 470 Pool together CJR episodes anchored by MS-DRGs 469 and 470 for target price calculations and apply national case-mix factors to that family average to calculate the DRG-level targets. Discount Factor Quality Measures and Display of Quality Metrics Implementation of Quality Measures for Reconciliation Payment Eligibility Apply 2% discount to hospital's hospital-specific and regional historical spending to determine target price. When calculating savings: 2% discount for years 1-5. When calculating losses owed to CMS: Upside-only year 1; 1% discount for year 2; 2% discount for years 3-5. Discount rate for savings and losses is decreased by 0.3 % points if hospital voluntarily submits patientreported outcome measure data. Hospitals would receive target prices for each scenario. Eligibility to receive savings predicated on meeting or exceeding performance threshold on: 1) Hospital-level 30-day, all-cause RSRR following elective primary THA and/or TKA (NQF #1551), an administrative claims-based measure 2) Hospital-level RSCR following elective primary THA and/or TKA (NQF #1550), an administrative claims-based measure 3) HCAHPS Survey measure. Will incorporate a composite score methodology to link quality and payment. Maximum discount factor increased to 3%. Higher quality performance translates to lower discount factor. Calculating savings: Years 1-5: 3% - 1.5% Calculating losses/repayment: Year 1: Upside-only Years 2-3: 2% - 0.5% Years 4-5: 3% - 1.5% Hospital-level 30-day, all-cause RSRR following elective primary THA and/or TKA (NQF #1551) removed. 8

9 Adjust the Payment Methodology for Voluntary Submission of Data for Patient- Reported Outcome Measure Measure Risk- Adjustment Applicable Time Period Methodology to Determine Performance on the Quality Measures Measure under CMS development: Hospital-Level Performance Measure(s) of Patient-Reported Outcomes Following Elective Primary THA or TKA measure or both ("THA/TKA patient-reported outcome-based measure"). Voluntary submission results in 0.3% point decrease in discount amount. All 3 proposed measured are risk-adjusted. Use 3-year rolling performance period for HSRR and HSCR measures. Use 4 consecutive quarters for HCAHPS. Use 12-month intervals beginning between Jul. 1 and Dec. 31, 2016 for voluntarily submitted data. CJR performance compared to national distribution of measure results for each of these measures obtained through HIQR program. To be considered to have successfully reported the voluntary data collection and submission for the THA/TKA voluntary data: Hospital data must be submitted on at least 70% of their eligible elective primary THA/TKA patients. Eligible patients include those having THA/TKA procedure date during the anchor hospitalization at least 366 days prior to the end of the data collection period, but within 60 days of the end of the most recent 12 month period. CMS will incorporate the successful submission of THA/TKA voluntary PRO data into the CJR composite quality score, awarding points to participant hospitals who successfully submit these data instead of the 0.3% decrease in discount. All measures are risk adjusted. THA/TKA complications measure not adjusted for SES. Use 3-year rolling performance period for the HSCR measure. Use 4 consecutive quarters for HCAHPS. For the PRO, required submission dates vary depending on the calendar year. Submission of PRO data and risk variables must occur within 60 days of the most recent performance period. CMS included the performance periods for submission of preoperative and post-operative data for years in table 30 (page 818) in the final rule. For year 1, hospitals would be required to submit data for 50% of eligible procedures or a total of 50 eligible procedures during the data collection period. This number continues to increase until 2019 (submission of data required for either 80% or 200 eligible procedures). 9

10 Thresholds for Establishing Reconciliation Payment Eligibility In order to receive savings, a hospital's measure result must be at or above the 30th percentile of the national hospital measure results calculated for all HIQR program participant hospitals for each of the 3 measures for each performance period. Increase threshold to 40% for years 4-5. Failure to achieve threshold for 1 or more measures would result in ineligibility to receive reconciliation payments. Replace performance percentile thresholds with composite score methodology. Quality measure weights in composite score: Hospital-level RSCR following elective primary THA and/or TKA (NQF #1550) = 50% HCAHPS Survey (NQF #0166) = 40% Voluntary PRO = 10% Must have minimum composite score of 4.0 to be eligible to receive reconciliation payments. Magnitude of score inversely related to size of discount factor. CMS will reward improvement. CMS will add into the composite quality score 10% of the maximum value for one or both of the required measures, as applicable, which would equal 1 point for the THA/TKA Complications measure (NQF #1550) or 0.8 point for the HCAHPS Survey measure (NQF #0166), for those participant hospitals that demonstrate substantial improvement from the prior year's measure performance percentile on that measure (improving 3 deciles or more in comparison to the national distribution of measure results.) 10

11 Thresholds for Establishing Reconciliation Payment Eligibility Reconciliation Payment Reconciliation Hospitals w/ "insufficient volume" will be assumed to be performing at the threshold level. Performance period reconciled twice. CMS will retrospectively reconcile a hospital's CJR actual episode payments against the target price for claims submitted up to 2 months following the end of a performance year (would capture claims submitted by March 1st of following year). Would calculate NPRA in Q2 of that calendar year. (Example: 2016 performance year reconciled in Q ) Would re-reconcile payments during the subsequent year to account for claims run out and overlap with other CMS programs. CMS will assign participant hospitals without a measure value to the 50th performance percentile. A participant hospital will not have a value for the THA/TKA Complications measure (NQF #1550) if the hospital does not meet the minimum case count of 25 cases in the 3 year measurement period. A participant hospital will not have a reported value for the HCAHPS Survey measure (NQF #0166) if it did not meet the minimum of 100 completed surveys and did not have 4 consecutive quarters of HCAHPS data. Finalized. 11

12 Overlaps w/ Other Innovation Center and CMS Programs CJR Beneficiary Overlap with BPCI Episodes Accounting for CJR Reconciliation Payments and Repayments in Other Models and Programs Accounting for PBPM Payments in the Episode Definition BPCI LEJR episodes take precedence over CJR episodes. In additional to calculating hospital-specific reconciliation amounts for CJR episodes, CMS will calculate beneficiary-specific reconciliation amounts to assess total cost of care for overlapping beneficiaries. CMS will make available information about beneficiaries in multiple programs. CMS will determine whether services paid by PBPM payments are excluded from the CJR episode on a model by model basis based on their funding source and clinical relationship to CJR episodes. Services paid by PBPM payments made under the MAPCP model would be included in CJR episodes, while PBPM payments associated with other models would be excluded. Finalized. CMS clarified that a patient may be in a CJR episode and non-lejr BPCI episode simultaneously. Savings for each episode would be calculated separately, and no recoupment methodology that would prevent an overlapping of savings was finalized. CMS rejected requests to allow Medicare ACOs to opt out of CJR. 12

13 Accounting for Overlap with Shared Savings Programs and Total Cost of Care Models Proposals to Limit or Adjust Hospital Financial Responsibility Limit on to Raw NPRA Contribution to Repayment Amounts (Stop Loss limit) Limit on Raw NPRA Contribution to Reconciliation Payments (Stop Gain limit) Policies for Certain Hospitals to Further Limit Repayment Responsibility When overlap occurs, CMS will attribute Medicare savings accrued during CJR time period to CJR to the extent possible. Will ensure that CJR Medicare savings (discount amount) are not paid out under the following total cost of care models: CPCi, OCM, and MAPCP. For ACO models, CMS will make an adjustment to the CJR reconciliation amount to account for any of the applicable discount for an episode that resulted in Medicare savings that is paid back through an ACO model (exception: LEJR beneficiary aligned with ACO of which participant hospital is not a member.) NPRA repayments to CMS limited to 10% of target amount in year 2, and 20% of target amount for years 3-5. Limit positive NPRA paid by CMS to hospital to 20% of target amount for all 5 performance years. A stop-loss limit of 3% in year 2 and 5% (of the target amount) for years 3-5 will apply to rural hospitals, SCHs, Medicare Dependent Hospitals and Rural Referral Centers (RCCs). NPRA repayments to CMS limited to 5% of target amount in year 2, 10% in year 3, and 20% of target amount for years 4-5. Stop-gain limits changed to match stop-loss thresholds. NPRA payments to participant hospitals limited to 5% of target amount in year 2, 10% in year 3, and 20% of target amount for years

14 Hospital Responsibility for Increased Post- Episode Payments Appeal Procedures for Reconciliation Payment Calculation Error Dispute Resolution CMS will sum all Part A and B payments (include those excluded from CJR episode definitions) accrued during 30 days immediately following conclusion of CJR episode, and monitor whether the average 30-day postepisode spending for a participant hospital in any given performance year is greater than 3 standard deviations above the regional average 30-day post-episode spending. Starting in year 2, a hospital would have to repay CMS amounts in excess of this 3 standard deviation threshold. When an Awardee achieves a positive NPRA, CMS will issue payment to the Awardee within 30 calendar days from the issue date of the CJR Reconciliation Report. Initial positive NPRAs that are reduced in subsequent reconciliations will have to be paid back for year 1, and in years 2-5 will be deducted from subsequent years' positive NPRAs. Repayments of negative NPRAs must be made within 30 days of receiving reconciliation results. Failure to pay will result in CMS withholding Medicare payments. The participant hospital would be solely liable for the repayment of the negative repayment amount to CMS. Participants may submit error reports to CMS. They must be submitted within 30 days of receipt of reconciliation results. If a hospital submits an error report on time, the hospital may further pursue the issue through a reconsideration review. No change except timeline for repayment and submitting error report. Timeline extended to 45 days following receipt of reconciliation results. Participant hospitals must submit error reports within 45 days of receipt of reconciliation results. 14

15 Financial Arrangements, Beneficiary Incentives, and Proposed Program Rule Waivers and Amendments Financial Arrangements and Beneficiary Incentives Financial Arrangements Under the CJR Model Hospitals may engage in financial arrangements with non-providers for support with tasks such as data analysis and care redesign. Relationships must satisfy parameters set by existing laws and regulations. "CJR collaborator" refers to SNFs, HHAs, LTCHs, IRFs, PGPs, physicians, non-physician practitioners, and outpatient therapy providers who directly furnish care to CJR beneficiaries during an episode and/or participate in CJR care redesign activities. Financial arrangements between hospitals and CJR collaborators must be outlined in a CJR Sharing Arrangement, and a written Participation Agreement must also exist between the entities. "Participation Agreement" changed to "collaborator agreement". CMS clarifies that opt-out physicians are ineligible to be a CJR collaborator. Requires the participant hospital to develop a written set of criteria that it will use to determine the selection of all CJR collaborators. Those policies must be related to, and inclusive of, the quality of care to be delivered to beneficiaries during a CJR episode. Participant hospitals must include the methodology the participant hospital will use to determine gainsharing payments in its collaborator agreements. The methodology must be based, at least in part, on the quality of care to be delivered to beneficiaries during a CJR episode. 15

16 Financial Arrangements Under the CJR Model CJR Sharing Arrangement Requirements Gainsharing payments to CJR collaborators may consist of reconciliation payments and internal cost savings (ICS). Gainsharing payments must be distributed on an annual basis. CJR collaborators can share in downside risk, and when CJR collaborators make a payment to a hospital it will be called an "alignment payment." CMS requires that sharing arrangements include much of the information currently outlined in BPCI gainsharing agreements. CMS does not propose to require hospitals to periodically report this information. CMS clarified that alignment payments may only be distributed once NPRA is calculated. No change to proposal. CMS added requirement that sharing arrangements, included in collaborator agreements, must be entered into before care is furnished to CJR beneficiaries under the terms of the arrangement. 16

17 Gainsharing Payment and Alignment Payment Conditions and Restrictions 1) Receipt of gainsharing payments cannot be predicated on volume/value of referrals; 2) Gainsharing is voluntary; 3) Gainsharing payments must be distributed on an annual basis; 4) Alignment payments may be made at any time interval after NPRA is calculated; 5) CJR Sharing Arrangements must stipulate that CJR collaborators with any integrity issues may not receive gainsharing payments; 6) In a CY, aggregate Alignment Payments must be < 50% of hospital's repayment amount due to CMS. If no repayment amount is due, alignment payments must = $0; 7) Alignment payment made by a single CJR collaborator is limited to 25% of the hospital's repayment amount to CMS; 8) Gainsharing payments made to physician CJR collaborators are capped at 50% of total Medicare amounts approved under the PFS for services furnished by the physician to the hospital's CJR beneficiaries during a CY; and 9) Gainsharing payments made to PGP CJR collaborators are capped at 50% of total Medicare amounts approved under the PFS for services furnished by physician members of the PGP to the hospital's CJR beneficiaries during a CY. 17

18 Prohibits a PGP that is a CJR collaborator from retaining any portion of a gainsharing payment. Would require the PGP to distribute 100% of the gainsharing payment to the PGP's member physicians and nonphysician practitioners that provided care to CJR beneficiaries. CMS will allow PGPs that are CJR collaborators to retain all or a portion of a gainsharing payment that the PGP receives from a participant hospital. CMS defines a PGP as an entity that furnishes clinical patient care services, including evaluation and management services, or professional surgical services. A PGP CJR collaborator may distribute all or a portion of any gainsharing payment it receives from the hospital only in accordance with a "distribution arrangement" to a "practice collaboration agent." The PGP may not enter into a distribution arrangement with any member of the PGP that has a collaborator agreement in effect with a participant hospital. Documentation and Maintenance of Records CJR Sharing Arrangements and Participation Agreements are auditable. Requires contemporaneous documentation of collaborator agreements to ensure that agreements are entered into prior to the furnishing of care to CJR beneficiaries. Require that the the documentation for collaborator agreements include a description of the sharing arrangement; its date; the purpose; the provisions and scope of the arrangement; and the financial terms of the arrangement. Reiterates that hospitals are not required to periodically submit gainsharing information to CMS for review. Participant hospitals must maintain current and historical lists of CJR collaborators and update this information on the hospital website on a quarterly basis. 18

19 Beneficiary Incentives Under the CJR Model Compliance with Fraud and Abuse Laws Waivers of Medicare Program Rules General Post-Discharge Home Visits Participant hospitals may provide beneficiary incentives in the form of preventive care items or an item or service that advances a clinical goal for a CJR beneficiary. Example: post-surgical monitoring equipment. Hospitals must contain contemporaneous documentation for 10 years of items/services > $10. Items/services involving technology must < $1,000 and if >$50 must be retrieved from beneficiary at the end of the episode. The Secretary is considering whether waivers of fraud and abuse laws are necessary. CMS is still considering the appropriate vehicle for promulgating such waivers, which would be promulgated separately from this rule. Waivers would apply to CJR beneficiaries when the waiver is used to bill for a service that is furnished to the beneficiary even if the episode is later cancelled. If the waiver was used for a service for a beneficiary not in the CJR model at the time the service was furnished, the waiver would not hold. CMS would recoup the payment from the beneficiary and the hospital would have to repay the copayment/coinsurance to the beneficiary. CMS does not plan to waive the home-bound requirement for receipt of home health services. CMS will waive the "incident to" rule to allow a CJR beneficiary that does not satisfy requirements for home health services to receive up to 9 post-discharge home visits during an episode. Hospitals must contain contemporaneous documentation of items/services > $25. Items/services involving technology must be < $1,000 and if >$100 must be retrieved from beneficiary at the end of the episode. Require that beneficiary incentives must not be tied to the receipt of items or services from a particular provider or supplier. OIG promulgated information about waivers of fraud and abuse laws for CJR. That information can be accessed here: Abuse/PhysicianSelfReferral/Downloads/2015- CJR-Model-Waivers.pdf CMS clarified that this scenario would apply in the event that an episode is dropped due to a change in a beneficiary's coverage that occurs during the episode. The new HCPCS code G9490 for CJR model post-discharge home visits will have the same RVUs as HCPCS code G9187 for BPCI model post-discharge home visits. 19

20 Billing and Payment for Telehealth Services SNF 3-Day Rule Waivers of Medicare Program Rules to Allow Reconciliation Payment or Repayment Actions Resulting from the NPRA Quality Measures and Display of Quality Metrics used in the CJR Model Public Display of Quality Measures in the CJR Model Measure that Captures Shared Decision- Making Related to Elective Primary Total Hip and/or Total Knee Arthroplasty Waives the geographic site requirement for telehealth services as well as the requirement that the eligible telehealth individual be in an originating site when the otherwise eligible individual is receiving telehealth services in his or her home. Waives the 3-day hospital stay required for SNF payment starting in performance year 2. Eligible SNFs must have overall star rating of three stars or better for at least 7 of the preceding 12 months. Waives the requirements of sections 1813 and 1833(a) of the Act to the extent that they would otherwise apply to reconciliation payments or repayments from a participant hospital under CJR. CJR participant hospitals' quality measure results will be displayed on the Hospital Compare website. No developed measures; CMS seeks feedback on the opportunity to capture quality data related to shared decision-making. SNF must be eligible at the time of the CJR beneficiary's SNF admission. CMS still considering future development of the measure. If CMS does develop measure, the Agency would "propose through rulemaking or other means" before including in CJR. 20

21 Future Measures around Care Planning Future Measures for Use of Health IT and Health Information Exchange Data Sharing Beneficiary Claims Data Aggregate Regional Data Timing and Period of Baseline Data Frequency and Period of Claims Data Updates for Sharing Beneficiary- Identifiable Claims Data During the Performance Period Further measure development needed; CMS seeks comment on the appropriateness of a future quality measure which would assess the use of shared care plans in care of CJR beneficiaries. Not proposing to add a measure for certified health IT use for year 1, but seek comment on how to incorporate such a measure beginning in year 2. Seeks comment on frequency of data delivery. Will provide hospital-specific data from baseline period and quarterly updates during performance period. Beneficiary claims data will be available in 2 formats: 1) Summary claims data; and 2) Beneficiary-level raw claims data. Will provide high-level information (not beneficiaryidentifiable claims data) on the average episode spending for DRGs 469 and 470 in the participant hospital's region. Will make data available within 60 days of receipt of request by participant hospital for data. Will make baseline data available to participant hospitals no sooner than 60 days after Jan. 1, Requests will not be accepted until the model has begun. Will make baseline data for up to 3-year period available. Will provide updated beneficiary claims data (that would represent up to 6 quarters of information) available on a quarterly basis upon request. CMS still considering future development of the measure. If CMS does develop measure, the Agency would propose through notice and comment rulemaking. No action taken, but considering for the future. Both data formats will be provided to participant hospitals upon request. Will make data available prior to April 1, 2016 start date. Participant hospitals must request data. Will make data "available "no less frequently" than on a quarterly basis with the goal of making these data available on a monthly basis "if practicable." Hospitals need only request data once, at the onset of CJR. 21

22 Legal Permission to Share Beneficiary- Identifiable Data Monitoring and Beneficiary Protection Beneficiary Choice and Beneficiary Notification Beneficiaries may opt-out of having their data shared with hospitals by calling Medicare. CMS will notify beneficiaries of option to opt out. Participant hospitals will only be allowed to request beneficiary-identifiable claims data for beneficiaries who: 1) have been furnished a billable service by the participant hospital corresponding to the episode definitions for CJR; and 2) have not opted-out of claims data sharing. Patients may not opt out of CJR. Beneficiary choice of providers must be maintained. Hospitals must require all providers and suppliers with which they have a CJR Sharing Arrangement to provide a beneficiary notification prior to ordering an admission for a joint replacement. If a Sharing Arrangement does not exist, the hospital must provide the beneficiary notification. Beneficiaries cannot opt-out of having their data shared. A hospital need only make a single request in order to receive data during their participation in the model. Beneficiaries cannot opt-out of having their data shared. On admission, a hospital must provide beneficiaries with a general notice of the existence of the model and of certain beneficiary rights. Physicians must provide beneficiary notification once decision is made to have surgery. Hospital must provide beneficiary with list of all PAC providers, but can note preferred providers. Hospital must provide beneficiary list of providers with whom a sharing arrangement exists. Hospital must make beneficiary aware of financial liability in the event the patient is discharged after less than 3 days to a SNF that does not qualify for the waiver. 22

23 Monitoring for Access to Care Monitoring for Quality of Care CMS will monitor participant hospitals' claims data for issues such as changes in case mix between the baseline and performance period to identify potential cherrypicking, and will publish the data. CMS will audit participant hospitals' and CJR collaborators' claims to ensure beneficiaries have received access to medically necessary care. Participant hospitals must provide patients with "a complete list of all available post-acute care options in the service area consistent with medical need, including beneficiary cost-sharing and quality information." This proposal does not prevent hospitals from recommending preferred providers in accordance with existing law. CMS outlined ability to retain reconciliation payment if payment is linked to inappropriately provided or withheld care. 23