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August 10, 2016

New MACRA Proposed Rule Provisions Impact Orthopaedic Bundled Payments

Comprehensive Care for Joint Replacement (CJR) and Bundled Payments for Care Improvement (BPCI) models now qualify as Advanced Alternative Payment Model

WASHINGTON (August 10, 2016)—On July 25, 2016, the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) released a new proposed rule which supplements the recent proposed Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rule in a continuous effort to shift Medicare payments from quantity- to quality-based models. The proposed rule includes new cardiac care bundled payment models and incentives to increase cardiac rehabilitation usage, but also alters an existing bundled payment model for total joint arthroplasty and potentially allows it to qualify as an Advanced Alternative Payment Model (APM). Inclusion of the Comprehensive Care for Joint Replacement (CJR) bundled payment model and a new Bundled Payments for Care Improvement (BPCI) voluntary model expands the original proposed Quality Payment Program rules on Advanced APMs under MACRA and creates new pathways for physicians to qualify for increased payment incentives beginning in 2018.
The American Association of Orthopaedic Surgeons (AAOS) has long argued that the Medicare beneficiary population receiving care for hip fracture is significantly different from the patient population receiving elective hip and knee arthroplasty. “We’re encouraged by the inclusion of CJR and the new BPCI voluntary models into MACRA Advanced APMs, and laud the CMS acknowledgement of a difference in patient risk profile by creating a new hip fracture bundle,” says AAOS President Gerald R. Williams, Jr., MD.
According to the CMS proposed rule:
  • A new surgical hip/femur fracture treatment (SHFFT) bundled payment model initiated by hip and femur procedure claims may qualify as an Advanced APM.
  • Two different tracks will be implemented within the SHFFT and CJR models:
  • Participants who meet proposed requirements for use of Certified Electronic Health Record Technology (CEHRT) and financial risk would be in Track 1 (an Advanced APM track).
  • Participants who do not meet CEHRT and financial risk requirements would be in Track 2 (a non-Advanced APM track).
Since April 2016, the CJR model has required mandatory hospital participation in 67 areas of the United States. The AAOS expresses concern that the SHFFT model—to be tested beginning on July 1, 2017 for five performance years in the same hospitals participating in the CJR model—is similarly a mandatory, hospital-led bundled payment model that does not offer a sufficient implementation timeline. The AAOS will be providing comments on this proposed rule to CMS, requesting to see more details on physician gainsharing guidelines and results of existing BPCI models.
“Patient care remains of the utmost importance to the AAOS and its members,” says Dr. Thomas C. Barber, chair of the AAOS Council on Advocacy. “Minimizing surgical complications and hospital readmissions, and speeding patient recovery are paramount. While the proposed policy changes released this week are improvements over the original proposed Quality Payment Program rules, we will keep working with CMS to ensure timely, high-quality, affordable specialty care delivery improvements for all Americans.”
The AAOS commends members of Congress and CMS leadership for acknowledging concerns about the exclusion of the CJR and BPCI models in the original proposed list of Advanced APMs. Extension of CJR, and potentially qualifying a new BPCI model, helps create greater patient access to even more effective and affordable specialty care.
For more information, visit or read the CMS fact sheet.
Follow the AAOS Office of Government Relations on Twitter: @AAOSAdvocacy.
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