CMS releases first CJR bundled payment results: What to know

CMS’ first mandatory bundled payment model, the Comprehensive Care for Joint Replacement (CJR) program, launched April 1.

PriceRecently, CMS released the first data feed from the program. The information, which includes data on relevant episodes of care that began from April 1 to early June, is critical to the more than 750 hospitals participating in the program.

Read: Three ways hospitals can prepare for CMS’ CJR model

To gain more insight into the data and what it means for readers, Managed Healthcare Executive spoke with Kelly Price, vice president and chief of healthcare data analytics at DataGen, a subsidiary of the Healthcare Association of New York State.

Quick program overview

The CJR program includes episodes triggered by hospitalizations of eligible Medicare fee-for-service beneficiaries discharged in the following diagnosis related groups (DRGs):

• MS-DRG 469: Major joint replacement or reattachment of lower extremity with major complications or comorbidities.

• MS-DRG 470: Major joint replacement or reattachment of lower extremity without major complications or comorbidities.

The episodes include the hospitalization and 90 days post-discharge, and all Part A and Part B services associated with the care (with a few exceptions).

Read: CMS' mandatory bundled payment model: How to prepare

After each performance year, actual episode spending will be compared with episode target prices set by CMS. If actual spending is lower than target prices and the hospital meets quality metrics, the hospital can share in the savings; if actual spending is more than the CMS targets, hospitals share in the losses.

Hospitals will experience no risk in performance year 1 (which began April 1), meaning they will not need to repay Medicare if they do not meet quality and cost targets.

What the initial data included

The data released by CMS included some surprises, such as a “rerelease” of the CJR baseline data and targets for hospitals, says Price, noting that the change was made to correct an error in the original release.

“It was a very small change and it only served to increase some of the targets by about a half a percentage point,” Price says. “I think what is important to understand there is that with all of these new programs, CMS is continuing to refine their methodology. It’s extremely complicated and so there are errors periodically.”

Read: MCOs must reinvent themselves due to bundled payment growth

CMS also changed the format in which it released the data, in an effort to provide additional information to hospitals and make it easier for them to use the data, says Price.

These format changes included files that contained aggregate data that hospitals can use to determine how many episodes were included in each month, and files on claim level data “where you can see the truth in detail,” she says.

Next: What the initial data feed did not measure

What the initial data feed did not measure

In many cases, the first data feed does not provide hospitals with full information on whether they met financial targets, because the data feed only included claims submitted and paid when the data was released. In other words, some claims may not have been paid by the time CMS assembled the data, because the CJR covers a 90-day episode. 

“You can’t use this data to evaluate whether you are performing well financially yet, you just can’t,” says Price. “If you do, and you compare yourself to [financial] targets … you’ll get a big surprise in October or November when CMS releases the next iteration of data and most of those episodes are complete in terms of claims lag.”

In October or November, when CMS releases the second data feed, hospitals will have a much more comprehensive picture of their financial performance compared to the targets, she says.

How to use the data

Despite the fact that there are gaps in this data, there is some value hospitals can glean from it and some actions they should take as a result, says Price.

The first thing hospitals should consider is the number of CJR episodes CMS attributed to them and for which patients, she says, noting that this information is available for April and May, and partially for June.

“CMS is telling you in this data set which of your patients they think could initiate a bundle for you,” Price says. “Take a look at that and make sure that these are also the patients that you identified, that you didn’t miss anyone, that you understand how and why CMS’ list might be different from yours so that you can start to wrap your head around the program.”

To be successful in the CJR program moving forward, hospitals need to be able to identify affected patients early on, so that they can target their quality and cost improvement efforts accordingly, she says.

In addition, hospitals can use the data to begin assessing their processes associated with episodes of care, and determine what needs to change in order to be successful, says Price.

“At least for the episodes that started in April and even through the middle of May, the [data includes claims related to the] first place the patient went after discharge,” she says. “You can take a look at that information, and if you put in place a post-acute strategy, you can start to look at whether you seem to be following it.”

Overall, Price advises hospitals to use the data to get a sense of magnitude and direction of the CJR program. “The first quarter is the time to grab the attention of the senior leadership and say, ‘Look, here’s what’s going on. If we don’t do something things will get worse,’” she says.