AAOS Has Concerns Over CMS’ Proposed Joint Replacement Rule

On February 20, 2020, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to extend and make changes to the Comprehensive Care for Joint Replacement (CJR) Model. In response, the American Association of Orthopaedic Surgeons (AAOS) Council on Advocacy released a statement welcoming some changes but also expressing concerns and opposing CJR’s mandatory nature.

The CJR model was intended to provide enhanced support and care for Medicare beneficiaries who are receiving hip and knee replacements, which are the most common inpatient surgeries for Medicare beneficiaries. Hip and knee replacements are also commonly known as lower extremity joint replacements (LEJR).

Initially scheduled to run through December 31, 2020, the CJR Model “tests bundled payment and quality measurement for an episode of care associated with hip and knee replacements to encourage hospitals, physicians, and post-acute care providers to work together to improve the quality and coordination of care from the initial hospitalization through recovery.”

The new CMS proposed rule includes “incorporating outpatient hip and knee replacements into the episode of care definition, the target price calculation, the reconciliation process, the beneficiary notice requirements, gainsharing caps, and the appeals process.” The proposed rule extends the model three years, through December 31, 2023.

In response to the proposed rule, AAOS Council on Advocacy Chair Wilford K. Gibson, M.D., F.A.A.O.S. stated, “The AAOS is encouraged by the new opportunities proposed which recognize the role and stewardship of practitioners in lower extremity joint replacement (LEJR) care. Welcome changes include the incorporation of hip and knee replacements in the outpatient setting, as well as a new risk adjustment methodology to account for patient health complexity. It is interesting too that CMS is considering a similar model for ambulatory surgical centers.”

While welcoming some changes, Dr. Gibson also expressed concern with some of the proposed changes. He stressed AAOS’ opposition to the mandatory nature of CJR and CMS’ intention to readjust the target price using only the most recent year of claims data. Dr. Gibson explained that using only the most recent year’s data—as opposed to three years’ worth—would be “likely to hamper financial performance of model participants and have other unintended consequences.”

Dr. Gibson continued, “We are also concerned with the agency’s decision to continue with hospital leadership as opposed to physician leadership and exclude voluntary participants, many of whom have invested significant time, energy, and resources promoting value-based care.”

Dr. Gibson noted that AAOS intends to submit formal comments on the proposed rule. He stated, “We look forward to submitting formal comments and continuing to work with the agency on developing patient safety and appropriate site of care guidelines for LEJR procedures.”

Comments on the CJR proposed rule are due to CMS by April 24, 2020.