Medicare Program: Comprehensive Care for Joint Replacement Model Three-Year Extension and Changes to Episode Definition and Pricing; Medicare and Medicaid Programs; Policies and Regulatory Revisions in Response to the COVID-19 Public Health Emergency rule (2021)

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The Medicare Program: Comprehensive Care for Joint Replacement Model Three-Year Extension and Changes to Episode Definition and Pricing; Medicare and Medicaid Programs; Policies and Regulatory Revisions in Response to the COVID-19 Public Health Emergency rule is a significant rule issued by the Centers for Medicare and Medicaid Services (CMS) effective July 2, 2021, that extends the length of the Comprehensive Care for Joint Replacement (CJR) model through December 31, 2024, pursuant to notice-and-comment rulemaking beginning on April 1, 2016.[1]

HIGHLIGHTS
  • Name: Medicare Program: Comprehensive Care for Joint Replacement Model Three-Year Extension and Changes to Episode Definition and Pricing; Medicare and Medicaid Programs; Policies and Regulatory Revisions in Response to the COVID-19 Public Health Emergency
  • Action: Final rule
  • Type of significant rule: Economically significant rule

    • Timeline

    The following timeline details key rulemaking activity:

    Background

    The Comprehensive Care for Joint Replacement (CJR) model, implemented in 2016, focuses on improving care and efficiency for Medicare beneficiaries undergoing hip and knee replacements. It employs bundled payments and quality measures to incentivize collaboration between hospitals, physicians, and post-acute care providers, and initial evaluations have shown cost reduction without compromising care quality. Changes proposed in 2020 include expanding the definition of episodes to include outpatient procedures and modifying payment calculations for sustainability and aim to adapt the model to evolving healthcare trends and improve its effectiveness.

    Summary of the rule

    The following is a summary of the rule from the rule's entry in the Federal Register:

    “ This final rule extends the length of the Comprehensive Care for Joint Replacement (CJR) model through December 31, 2024 by adding an additional 3 performance years (PYs). PY 6 will begin on October 1, 2021 and end on December 31, 2022; PY 7 will begin on January 1, 2023 and end on December 31, 2023; and PY 8 will begin on January 1, 2024 and end on December 31, 2024. In addition, this final rule revises certain aspects of the CJR model including the episode of care definition, the target price calculation, the reconciliation process, the beneficiary notice requirements, and the appeals process. In addition, for PY 6 through 8, this final rule eliminates the 50 percent cap on gainsharing payments, distribution payments, and downstream distribution payments for certain recipients. This final rule extends the additional flexibilities provided to participant hospitals related to certain Medicare program rules consistent with the revised episode of care definition.[2] ”

    [1]

    Summary of provisions

    The following is a summary of the provisions from the rule's entry in the Federal Register:[1]

    “ In response to the publication of the February 2020 proposed rule, we received approximately 66 timely pieces of correspondence. Contained within these 66 pieces of correspondence were approximately 810 discrete comments concerning the extension of the CJR model by 3 years, the CJR model episode of care definition, the target price calculation, the reconciliation process, the elimination of the 50 percent cap on gainsharing, the beneficiary notice requirements and discharge planning notice, program waivers, the appeals process, evaluation, and regulatory impact. Additionally, we received many comments regarding our request for comment on new LEJR focused models that would include ASCs. These comments were from groups representing medical societies, hospital associations, hospitals, and medical centers. The remaining comments were from individual physicians and individual commenters.

    We received several comments that were in general agreement with the proposed rule as well as several comments that were in general disagreement with the proposed rule. Summaries of these comments and our responses are discussed later in this section. Finally, we received several comments that are considered out of scope. Although comments that are out of the scope of this rule are not addressed with the policy responses in this final rule, we are taking each comment into consideration and may address these comments in future rulemaking as warranted. Summaries of the public comments that are within the scope of the proposed rule and our responses to those public comments are set forth in the various sections of this final rule under the appropriate heading.[2]

    		”

    Significant impact

    See also: Significant regulatory action

    Executive Order 12866, issued by President Bill Clinton (D) in 1993, directed the Office of Management and Budget (OMB) to determine which agency rules qualify as significant rules and thus are subject to OMB review.

    Significant rules have had or might have a large impact on the economy, environment, public health, or state or local governments. These actions may also conflict with other rules or presidential priorities. Executive Order 12866 further defined an economically significant rule as a significant rule with an associated economic impact of $100 million or more. Executive Order 14094, issued by President Joe Biden (D) on April 6, 2023, made changes to Executive Order 12866, including referring to economically significant rules as section 3(f)(1) significant rules and raising the monetary threshold for economic significance to $200 million or more.[1]


    The text of the Medicare Program: Comprehensive Care for Joint Replacement Model Three-Year Extension and Changes to Episode Definition and Pricing; Medicare and Medicaid Programs; Policies and Regulatory Revisions in Response to the COVID-19 Public Health Emergency rule states that OMB deemed this rule economically significant under E.O. 12866:

    “ The Office of Management and Budget has designated this final rule as an “economically significant” rule under E.O. 12866 and a “major rule” under the Congressional Review Act (CRA).[2] ”

    Text of the rule

    The full text of the rule is available below:[1]

    See also

    External links

    Footnotes

    1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 Federal Register, "Medicare Program: Comprehensive Care for Joint Replacement Model Three-Year Extension and Changes to Episode Definition and Pricing; Medicare and Medicaid Programs; Policies and Regulatory Revisions in Response to the COVID-19 Public Health Emergency," July 2, 2021
    2. ↑ 2.0 2.1 2.2 Note: This text is quoted verbatim from the original source. Any inconsistencies are attributable to the original source.
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