In brief:

• Proposed rule would reduce the number of geographic areas required to participate in the Comprehensive Care for Joint Replacement (CJR) bundling model from 67 to 34
• Low-volume and rural hospitals in all 67 areas would not be required to participate in CJR, but could do so voluntarily
• Plans to implement a bundling model for cardiac care have been shelved, as are plans to expand CJR to include care of hip and femur fractures
• Requirements for becoming a qualified provider in the CJR as an advanced alternative payment model would be broadened to include clinicians who don't have a financial arrangement with a facility but who are employed by the facility or have a contractual agreement

The US Centers for Medicare and Medicaid Services (CMS) wants to significantly scale back the knee and hip joint replacement bundled care model and plans to cancel expansion of bundled care models to cardiac care and hip/femur fractures. The announcements were made as part of a package of proposals unveiled on August 15 that also includes some loosening of requirements for a provider to be considered as a "qualifying provider" under the joint replacement bundle program.

The hip and knee bundle program, known as the Comprehensive Care for Joint Replacement (CJR) model, launched in 2016 as the first-ever attempt by CMS to mandate bundled care—in the case of CJR, that requirement applies to 67 different geographic areas covering some 800 hospitals. Under the proposed rule change, the number of geographic areas required to participate in CJR would drop to 34, leaving participation voluntary for all hospitals in the other 33 areas, or about 350 facilities. CMS estimates that 60 to 80 hospitals will choose to voluntarily participate. Hospitals that can and do decide to opt out of the program will have episodes beginning at any point during 2018 cancelled.

In addition to reducing the number of geographic areas required to participate in the CJR, CMS is proposing that low-volume and rural hospitals in the remaining 34 areas also be switched from mandatory to voluntary participation.

Per the same proposed rule, CMS would cancel a planned expansion of mandatory bundling to cardiac care, as well as expansion of the CJR to include care for hip and femur fractures. Those expansions originally were set to be put in place in February of this year but were later delayed until October 1, and then pushed back again to a January 2018 startup date. The proposed rule effectively would cancel the programs.

As CMS taps the brakes on the CJR, it also proposes making it easier for clinicians to be included as qualifying participants in the bundling program. Under the proposed rule, providers—including physical therapists—who don't have a financial arrangement with a facility in the CJR program, but who are either directly employed or contractually engaged with a participating hospital, would be accepted into the program. It would be up to the hospitals to supply CMS with an "engagement list" of those providers, and CMS would take it from there, using Medicare Part B claims data to decide whether a clinician can be considered an advanced alternative payment model qualifying provider. Clinicians who get the nod from CMS would not be required to report to under Merit-Based Incentive Payment System (MIPS) and could be eligible for payment bonuses up to 5%. (Because physical therapists are solely voluntary participants in MIPS as of now, they wouldn’t be subject to the MIPS reporting requirement even if they don’t participate in an advanced APM—but that could, and is expected to, change in future years.)

CMS has issued a fact sheet on the proposal. APTA staff are reviewing the proposed rule and will provide comments by the October 15 deadline.