Important Update: CJR Ending along with SNF Waiver for more than 300 Hospitals

I want to thank Millie in Florida to pointing out something very important that happened last week which affects more than 300 hospitals around the country.

The Comprehensive Care for Joint Replacement program also known as CJR, which began in 2016, ends on Dec. 31. As some may know, that is a program that looks at patients having lower extremity joint replacement and compares their total costs to Medicare over the period encompassing the surgery and 90 days after. The Centers for Medicare & Medicaid Services (CMS) establishes a target for each hospital and then shares any savings compared to that target with the providers or requires the providers to pay back money to Medicare if expenditures exceed that target.

But, and I will admit I didn’t know this, the ending date of Dec. 31and the 90 day measure period means the last patient to be part of CJR had their surgery on Oct. 3and not Dec. 31 as common sense would dictate. 

Now what does that mean for CJR hospitals? Well, if they are also in Bundled Payments for Care Improvement (BPCI) they can continue doing what they have been doing as the BPCI program, and if they will be in the upcoming (Transforming Episode Accountability Model (TEAM) program in 2026, they are well-prepared for it but will need to temporarily shift practices until 2026.

Most importantly though, unless there is another active waiver program in place, these CJR hospitals no longer have access to the 3-day SNF waiver. If their joint replacement patients need a SNF for rehabilitation, they have to do what the rest of us do and admit the patient as inpatient and keep them at least three days in order for their part A SNF benefit to be accessible, something they have not done for many years.

Now as a refresher, let me remind you what CMS said in the 2018 OPPS Final Rule when they took total knee arthroplasty off the inpatient only list. At 82 FR 52524, CMS states, “We agree that the physician should take the beneficiaries’ need for postsurgical services into account when selecting the site of care to perform the surgery. We would expect that Medicare beneficiaries who are selected for outpatient TKA would be less medically complex cases with few comorbidities and would not be expected to require SNF care following surgery.”

I find that compelling and have discussed it here before several times; if a patient has a legitimate inability to return to their previous living situation as they rehabilitate from their surgery, such as living alone or without adequate support or has stairs in their home to access the only bathroom, they can be admitted as inpatient and obviously kept for three days to be able to access their Part A SNF benefit. Of course, I would advise that there be proper documentation supporting that need and the patient receive appropriate therapy while in the hospital, and maybe they will improve enough to go home but if not, they have their qualifying stay. And don’t wait until post-op day 1 to determine they cannot go home. Plan ahead for their post-discharge needs before the patient even arrives.

Now to complicate things, I have recently heard that Livanta is not acknowledging this provision in the regulations and is denying inpatient admission for such patients unless there is an active medical issue that requires ongoing hospital care. I have yet to see confirmation of this, but I am working on it and if it is true, you know I will be ensuring that this is addressed by CMS because it is absolutely wrong.

Of course what we really need is for Congress to finally get rid of the three-day inpatient requirement. Many have tried and have yet to succeed.

Oh, to dream.

Programming note:

Listen to Dr. Ronald Hirsch live each Monday as he makes his Monday rounds on Monitor Mondays, 10 Eastern with Chuck Buck.