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Taking Stock After the First 100 Days of CJR
August 01, 2016

Taking Stock After the First 100 Days of CJR

Kelly Price is Vice President and Chief of Healthcare Data Analytics at DataGen, a healthcare data analytics and policy firm. Kelly has worked in healthcare finance for more than 20 years, focused on helping healthcare leaders and decision makers understand the impact of payment policy and regulations on their organizations. She provides decision support and education to hospitals and health systems across the country to help them prepare for the shift to value-based payment. Kelly works with hospital associations in 47 states and eight multi-state systems on Medicare and Medicaid reimbursement issues.
What the Initial Data Will—and Won’t—Reveal
Launched on April 1, 2016, the Comprehensive Care for Joint Replacement (CJR) model is the first mandatory bundled payment program from CMS. Affecting more than 750 hospitals in 67 markets, CJR creates a host of new challenges and opportunities for participants. To ensure that they are getting the most from the initial CJR data feeds from CMS, hospitals must understand what can and cannot be measured, and take steps now to address any issues.
Analyzing 2012 to 2014 Baseline Data: Factoring in Care Path and Physician Changes

Over the last few months, hospitals participating in CJR have had the opportunity to review their 2012 to 2014 baseline data. This data set provides an important comparison point, as it comprises two-thirds of participants’ initial targets and affords insight on a number of measures, including how often patients were discharged without requiring postacute institutional care, as well as infection and revision rates. However, participants should remember to take into account any changes in their care paths and joint replacement surgeons that occurred after this time period. 
What to Expect from the First CJR Data Feed
Accurate Patient Identification is Critical, Yet Challenging
Hospitals are eagerly awaiting the first round of performance period data, due to be disseminated by CMS shortly after the end of the first quarter of the program. The first CJR data feed will chiefly serve to indicate how well the system is able to identify attributed patients. Participants should analyze these data to determine which patients were missed and, conversely, which patients were identified as participating in the program who should not have been included.
It is critical, yet challenging, to properly identify CJR patients and include them in discharge planning, follow-up, and the required beneficiary notification. Ideally, this process should begin prior to or at admission. Factors that can hinder accurate identification include:
  • Assigning the incorrect Diagnosis Related Group (DRG) at admission—when a complication or other significant diagnosis arises during the hospital stay, the patient’s DRG assignment upon discharge may change. This is particularly impactful when a patient is admitted with DRG 470 but discharged with DRG 469, with complications and comorbidities that entail vastly different target amounts.
  • Mistaking fee-for-service patients for those enrolled in Medicare Advantage, who are excluded from the CJR program.
  • Patients may convert to end-stage renal disease status midway through the episode of care. The hospital may not know that these patients have been excluded from the program until reconciliation.
  • Attributing Bundled Payments for Care Improvement (BPCI) episodes to CJR—if 1 or more of a facility’s operating physicians participates in BPCI for joint services, the episode is attributed to the physician instead of the hospital. Because CMS may not identify these episodes until reconciliation, the hospital must institute measures to identify these physicians itself.
Why the Initial Data Feed Won’t Measure Financial Performance
Insufficient Time for Claims Run-out  
Unfortunately, because of insufficient claims run-out, the first data feed will not permit participants to accurately compare their financial performance with the target. The data feed will only include claims submitted and paid by the time the data are cut.
For example, an episode starting on April 1 will be complete by June 30; however, depending on when CMS cuts the data, claims submitted at the end of the episode may not yet be paid and therefore will not be part of the initial data feed (see figure 1). An episode that starts on May 1 and ends on July 30 will not even have been completed by the time the data are cut. Therefore, hospitals should anticipate that not all claims will be included—only the simplest of episodes will have complete data, such as when all care is provided in the first month and the patient has no other significant issues in the second and third months.
Figure 1.

Examples of why claims may be omitted from the performance period data feed include:
  • The patient is admitted to a skilled nursing facility (SNF) right before the data are cut and the claim has not yet been submitted.
  • The patient is readmitted just before the data are cut, and the claim has been submitted but not yet paid.
  • The 90-day episode is not complete by the time the data are cut—initially, this will include all episodes except those beginning on April 1 or 2.

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