[Federal Register Volume 86, Number 83 (Monday, May 3, 2021)]
[Rules and Regulations]
[Pages 23496-23576]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2021-09097]



[[Page 23495]]

Vol. 86

Monday,

No. 83

May 3, 2021

Part II





Department of Health and Human Services





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Centers for Medicare & Medicaid Services





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42 CFR Part 510





Medicare Program: Comprehensive Care for Joint Replacement Model Three 
Year Extension and Changes to Episode Definition and Pricing; Medicare 
and Medicaid Programs; Policies and Regulatory Revisions in Response to 
the COVID-19 Public Health Emergency; Final Rule

  Federal Register / Vol. 86 , No. 83 / Monday, May 3, 2021 / Rules and 
Regulations  

[[Page 23496]]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

42 CFR Part 510

[CMS-5529-F]
RIN 0938-AU01


Medicare Program: Comprehensive Care for Joint Replacement Model 
Three-Year Extension and Changes to Episode Definition and Pricing; 
Medicare and Medicaid Programs; Policies and Regulatory Revisions in 
Response to the COVID-19 Public Health Emergency

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Final rule.

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SUMMARY: This final rule extends the length of the Comprehensive Care 
for Joint Replacement (CJR) model through December 31, 2024 by adding 
an additional 3 performance years (PYs). PY 6 will begin on October 1, 
2021 and end on December 31, 2022; PY 7 will begin on January 1, 2023 
and end on December 31, 2023; and PY 8 will begin on January 1, 2024 
and end on December 31, 2024. In addition, this final rule revises 
certain aspects of the CJR model including the episode of care 
definition, the target price calculation, the reconciliation process, 
the beneficiary notice requirements, and the appeals process. In 
addition, for PY 6 through 8, this final rule eliminates the 50 percent 
cap on gainsharing payments, distribution payments, and downstream 
distribution payments for certain recipients. This final rule extends 
the additional flexibilities provided to participant hospitals related 
to certain Medicare program rules consistent with the revised episode 
of care definition.

DATES: These final regulations are effective July 2, 2021.

FOR FURTHER INFORMATION CONTACT: 
Bobbie Knickman, (410) 786-4161.
Heather Holsey, (410) 786-0028.

SUPPLEMENTARY INFORMATION: 

I. Background

A. Purpose

    The Comprehensive Care for Joint Replacement (CJR) model, which was 
implemented via notice-and-comment rulemaking and began on April 1, 
2016, aims to support better and more efficient care for beneficiaries 
undergoing the most common inpatient surgeries for Medicare 
beneficiaries: Hip and knee replacements (also called lower extremity 
joint replacements or LEJR). This 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. While initial 
evaluation results for the first, second, and third year of the CJR 
model,\1\ as well as an independent study in the New England Journal of 
Medicine,\2\ indicate that the CJR model is having a positive impact on 
lowering episode costs when CJR participant hospitals are compared to 
non-CJR participant hospitals (with no negative impacts on quality of 
care), changes in Medicare program payment policy and national care 
delivery patterns have occurred since the CJR model began. In order to 
update the CJR model to address recent policy changes and improve the 
model's ability to demonstrate savings, we issued a proposed rule 
titled ``Medicare Program: Comprehensive Care for Joint Replacement 
Model Three-Year Extension and Changes to Episode Definition and 
Pricing'', which appeared in the February 24, 2020 Federal Register (85 
FR 10516). In this rule, we proposed to change and extend the CJR model 
for an additional 3 performance years. We proposed to change the 
definition of a CJR model episode in order to address changes to the 
inpatient-only (IPO) list, which is a list published annually in the 
Outpatient Prospective Payment System (OPPS) rule and which contains 
procedure codes that will only be paid by Medicare when performed in 
the inpatient setting. Specifically, in response to the change in the 
calendar year (CY) 2018 OPPS rule (65 FR 18455), which removed the 
Total Knee Arthroplasty (TKA) procedure code from the IPO list, and the 
change in the CY 2020 OPPS rule (84 FR 61353), which removed the Total 
Hip Arthroplasty (THA) procedure code from the IPO list, we proposed to 
change the definition of an episode of care to include outpatient 
procedures for TKAs and to include outpatient procedures for THAs.
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    \1\ See evaluation reports section posted on the CJR model 
website at: https://innovation.cms.gov/initiatives/cjr.
    \2\ Barnett, Wilcock, McWilliams, Epstein, et al. ``Two-Year 
Evaluation of Mandatory Bundled Payments for Joint Replacement'' see 
https://www.nejm.org/doi/10.1056/NEJMsa1809010.
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    In addition to updating for changes in a hospital setting, the 
model also needed a more accurate and adaptable payment methodology 
that can sustain adjustments in practice and payment systems over time. 
Therefore, we proposed to make a number of changes to the target price 
calculation to improve sustainability and accuracy. Specifically, we 
proposed to change the basis for the target price from 3 years of 
claims data to the most recent 1 year of claims data to make the target 
price more representative of recent practice patterns, particularly 
post-acute care. We proposed to remove the national update factor and 
twice yearly update to the target prices and replace them with a 
retrospective trend factor at reconciliation to create greater 
consistency in the payment methodology with underlying practice and 
Medicare fee-for-service (FFS) payment system changes. We proposed to 
remove anchor factors and weights because they are no longer necessary 
and generate complexity.
    Additionally, we proposed a number of changes to the reconciliation 
process with similar goals of sustainability and payment accuracy. We 
proposed to move from two reconciliation periods (conducted 2 and 14 
months after the close of each performance year) to one reconciliation 
period that would be conducted six months after the close of each 
performance year to reduce hospital burden and for ease of 
administration. We proposed to add an additional episode-level risk 
adjustment beyond fracture status for greater payment accuracy. We 
proposed to change the high episode spending cap calculation 
methodology as the current methodology inaccurately capped high cost 
cases. We also proposed to the change the quality (effective or 
applicable) discount factors applicable to participants with excellent 
and good quality scores to better recognize high quality care.
    Since we proposed to change the definition of an episode of care to 
include procedures performed in the hospital outpatient department, for 
which the beneficiary would not be admitted as an inpatient to the 
participant hospital, we also proposed a change to the beneficiary 
notification requirements (which are currently tied to inpatient 
admission) such that CJR participant hospitals are also required to 
notify the beneficiary of his or her inclusion in the CJR model if the 
procedure takes place in a hospital outpatient department setting. We 
also proposed to make changes to the dates of publicly reported data 
used for quality measures and patient-reported outcomes (PRO) for the 3 
additional performance years to accommodate the extension period. In 
addition, we

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proposed to advance the Complications measure and Hospital Consumer 
Assessment of Healthcare Providers and Systems (HCAHPS) measure 
performance periods to add additional collection for PYs 6-8 in 
alignment with the performance periods used for PYs 1 through 5. For 
PRO, we proposed to advance the performance periods in alignment with 
previous performance periods as well as increase the thresholds for 
successful submission to add additional collection for PYs 6-8. 
Additionally, for the 3 additional performance years, we proposed to 
eliminate the 50 percent cap on gainsharing payments, distribution 
payments, and downstream distribution payments when the recipient of 
these payments is a physician, non-physician practitioner, physician 
group practice (PGP), or non-physician practitioner group practice 
(NPPGP) consistent with updates to other Innovation Center models. We 
also proposed to make changes to the appeals process in order to 
clarify the reconsideration review (second level appeal) process. 
Finally, in conjunction with the proposed change to include specific 
outpatient procedures in the CJR model episode definition, we also 
proposed to extend the waiver of the skilled nursing facility (SNF) 3-
day rule and the waiver of direct supervision requirements for certain 
post-discharge home visits for participant hospitals furnishing 
services to CJR beneficiaries in the outpatient setting as well. As 
outlined in section II.D.1. of this final rule we are extending the 
model for 3 performance years to generate the necessary evaluation 
findings under a revised payment methodology for the agency to consider 
expansion of the model.
    As further outlined in section II.D.2. of this final rule, we 
proposed that the extension of the CJR model would only apply to 
participant hospitals located in the 34 mandatory metropolitan 
statistical areas (MSAs) for whom participation has been mandatory 
since the beginning of the model in 2016. This proposal excludes rural 
and low-volume hospitals in the 34 mandatory MSAs and any voluntary 
hospitals in 33 voluntary MSAs that have opted into the model for PYs 3 
through 5. The model currently enrolls 139 voluntary, rural, and low-
volume hospitals. Excluding rural, low-volume, and voluntary hospitals 
from the model results in 330 hospitals in the 34 mandatory MSAs 
participating in PYs 6 to 8. We proposed conforming changes to the CJR 
model regulations at 42 CFR part 510.
    This final rule also finalizes policies in two interim final rules 
with comment (IFCs). Specifically, the IFC titled, Medicare and 
Medicaid Programs; Policy and Regulatory Revisions in Response to the 
COVID-19 Public Health Emergency,\3\ implemented a 3 month extension to 
CJR PY 5 such that the model would end on March 31, 2021, rather than 
ending on December 31, 2020, and provided an adjustment to the extreme 
and uncontrollable circumstances policy to account for the COVID-19 
pandemic. The second IFC titled, Additional Policy and Regulatory 
Revisions in Response to the COVID-19 Public Health Emergency,\4\ 
further extended PY 5 through September 30, 2021, created an episode-
based extreme and uncontrollable circumstances COVID-19 policy, 
provided two reconciliation periods for PY 5, and added Medicare 
Severity-Diagnostic Related Groupings (MS-DRGs) 521 and 522 for hip and 
knee procedures.
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    \3\ 85 FR 19230.
    \4\ 85 FR 71142.
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B. Summary of Costs and Benefits

    As shown in our impact analysis in section IV. of this final rule, 
we estimate that the CJR model changes we proposed will save the 
Medicare program approximately $217 million over the additional 3 model 
years. We note that our impact analysis has some degree of uncertainty 
and makes assumptions as further discussed in section IV. In addition 
to these estimated impacts, the goal of CMS' Center for Medicare and 
Medicaid Innovation (Innovation Center) models is to reduce program 
expenditures while preserving or enhancing the quality of care. Our 
evaluation results document that many participant hospitals are 
attempting to enhance their infrastructure to support better care 
management and to reduce costs. We anticipate there will continue to be 
a broader focus on care coordination and quality improvement through 
the CJR model among participant hospitals and other providers and 
suppliers within the Medicare program that may lead to better care 
management and improved quality of care for beneficiaries.

C. Statutory Authority and Background

    Under the authority of section 1115A of the Social Security Act 
(the Act), through notice-and-comment rulemaking, the Innovation Center 
established the CJR model in a final rule titled ``Medicare Program; 
Comprehensive Care for Joint Replacement Payment Model for Acute Care 
Hospitals Furnishing Lower Extremity Joint Replacement Services'' that 
appeared in the November 24, 2015 Federal Register (80 FR 73274) 
(referred to in this final rule as the ``November 2015 final rule''). 
The CJR model is a Medicare Part A and B payment model in which acute 
care hospitals in certain selected geographic areas receive 
retrospective bundled payments for episodes of care for lower extremity 
joint replacement or reattachment of a lower extremity (collectively 
referred to as LEJR). The CJR model holds participant hospitals 
financially accountable for the quality and cost of a CJR model episode 
of care and incentivizes increased coordination of care among 
hospitals, physicians, and post-acute care providers. All related care 
covered by Medicare Parts A and B within 90 days of hospital discharge 
from the LEJR procedure is included in the episode of care. The first 
CJR model performance period began April 1, 2016. At that time, the CJR 
model required hospitals located in the 67 MSAs selected for 
participation to participate in the model through December 31, 2020 
unless the hospital was an episode initiator for an LEJR episode in the 
risk-bearing phase of Models 2 or 4 of the Bundled Payments for Care 
Improvement (BPCI) initiative. Hospitals located in one of the 67 MSAs 
that participated in Model 1 of the BPCI initiative, which ended on 
December 31, 2016, were required to begin participating in the CJR 
model when their participation in the BPCI initiative ended.
    We issued a final rule titled ``Medicare Program; Comprehensive 
Care for Joint Replacement Payment Model for Acute Care Hospitals 
Furnishing Lower Extremity Joint Replacement Services; Corrections and 
Correcting Amendments,'' which appeared in the March 4, 2016 Federal 
Register (81 FR 11449), to correct a limited number of technical and 
typographical errors identified in the November 2015 final rule. We 
issued a final rule, which appeared in the January 3, 2017 Federal 
Register (82 FR 180), titled ``Medicare Program; Advancing Care 
Coordination Through Episode Payment Models (EPMs); Cardiac 
Rehabilitation Incentive Payment Model; and Changes to the 
Comprehensive Care for Joint Replacement Model (CJR)'' (referred to as 
the ``January 2017 final rule''), to implement the creation and testing 
of three EPMs and to make certain refinements to better align the CJR 
model with the new EPMs, to make minor technical improvements to the 
CJR model and to create an Advanced Alternative Payment Model (Advanced 
APM) track within the CJR model. We

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issued a final rule, which appeared in the May 19, 2017 Federal 
Register (82 FR 22895), titled ``Medicare Program; Advancing Care 
Coordination Through Episode Payment Models (EPMs); Cardiac 
Rehabilitation Incentive Payment Model; and Changes to the 
Comprehensive Care for Joint Replacement Model (CJR); Delay of 
Effective Date,'' which finalized May 20, 2017 as the effective date of 
the January 2017 final rule (82 FR 180) (referred to as the ``May 2017 
final rule''). The May 2017 final rule also finalized a delay to the 
effective date of certain CJR model regulations from July 1, 2017 to 
January 1, 2018. We issued another final rule, which appeared in the 
December 1, 2017 Federal Register (82 FR 57066), titled ``Medicare 
Program; Cancellation of Advancing Care Coordination Through Episode 
Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to 
Comprehensive Care for Joint Replacement Payment Model: Extreme and 
Uncontrollable Circumstances Policy for the Comprehensive Care for 
Joint Replacement Payment Model'' (referred to as the ``December 2017 
final rule''), that implemented further revisions to the CJR model, 
including giving rural and low-volume hospitals selected for 
participation in the CJR model as well as those hospitals located in 33 
of the 67 MSAs a one-time option to choose whether to continue their 
participation in the model through December 31, 2020 (that is, continue 
their participation through PY5). The December 2017 final rule also 
finalized further technical refinements and clarifications for certain 
payment, reconciliation and quality provisions, and implemented a 
change to increase the pool of eligible clinicians that qualify as 
affiliated practitioners under the Advanced APM track. An interim final 
rule with comment period was also issued in conjunction with the 
December 2017 final rule (82 FR 57092) in order to address the need for 
a policy to provide some flexibility in the determination of episode 
costs for providers located in areas impacted by extreme and 
uncontrollable circumstances. This extreme and uncontrollable 
circumstances policy was adopted as final in the final rule (83 FR 
26604) that appeared in the June 8, 2018 Federal Register, titled 
``Medicare Program; Changes to the Comprehensive Care for Joint 
Replacement Payment Model (CJR): Extreme and Uncontrollable 
Circumstances Policy for the CJR Model.''
    We issued the proposed rule, which appeared in the February 24, 
2020 Federal Register (85 FR 10516), titled ``Medicare Program: 
Comprehensive Care for Joint Replacement Model Three-Year Extension and 
Changes to Episode Definition and Pricing'' (hereinafter referred to as 
the ``February 2020 proposed rule''). In addition, in the April 24, 
2020 Federal Register (85 FR 22728), we published a document extending 
the public comment period of the February 2020 proposed rule for an 
additional 60 days (until June 23, 2020).
    We issued an IFC, which appeared in the April 6, 2020 Federal 
Register (85 FR 19230), titled ``Medicare and Medicaid Programs; Policy 
and Regulatory Revisions in Response to the COVID-19 Public Health 
Emergency'' (hereinafter referred to as the ``April 2020 IFC''). The 
April 2020 IFC (85 FR 19230) accounted for the impact of the COVID-19 
public health emergency (PHE) on CJR participant hospitals. We extended 
PY5 through March 31, 2021 and adjusted the extreme and uncontrollable 
circumstances policy to account for the COVID-19 PHE by specifying that 
all episodes with a date of admission to the anchor hospitalization 
that is on or within 30 days before the date that the emergency period 
(as defined in section 1135(g) of the Act) begins or that occurs 
through the termination of the emergency period (as described in 
section 1135(e) of the Act); actual episode payments are capped at the 
target price determined for that episode under Sec.  510.300.
    Additionally, CMS issued a proposed rule, which appeared in the May 
29, 2020 Federal Register (85 FR 32460) titled ``Medicare Program; 
Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals 
and the Long-Term Care Hospital Prospective Payment System and Proposed 
Policy Changes and Fiscal Year 2021 Rates; Quality Reporting and 
Medicare and Medicaid Promotion Interoperability Programs Requirements 
for Eligible Hospitals and Critical Access Hospitals (hereinafter 
referred to as the ``FY 2021 IPPS/LTCH proposed rule''). In the FY 2021 
IPPS/LTCH proposed rule (85 FR 32510), we solicited comment on the 
effect of the proposal to create new MS-DRG 521 and MS-DRG 522 on the 
CJR model and whether to incorporate MS-DRG 521 and MS-DRG 522, if 
finalized, into the CJR model's proposed extension to December 31, 
2023.
    We issued another IFC, which appeared in the November 6, 2020 
Federal Register (85 FR 71142), titled ``Additional Policy and 
Regulatory Revisions in Response to the COVID-19 Public Health 
Emergency'' (hereinafter referred to as the ``November 2020 IFC''). In 
the November 2020 IFC, we implemented four changes to the CJR model. 
First, we extended PY5 an additional 6 months, so PY5 ends on September 
30, 2021. Second, we made changes to the reconciliation process for PY5 
to allow two subsets of PY5 to be reconciled separately. Third, we made 
a technical change to include MS-DRGs 521 and 522 in the CJR episode 
definition, retroactive to inpatient discharges beginning on or after 
October 1, 2020, to ensure that the model continues to include the same 
inpatient LEJR procedures, despite the adoption of new MS-DRGs 521 and 
522 to describe those procedures. Lastly, we made changes to the 
extreme and uncontrollable circumstances policy for the COVID-19 PHE to 
adapt to an increase in CJR episode volume and renewal of the PHE, 
while providing protection against financial consequences of the COVID-
19 PHE after the extreme and uncontrollable circumstances policy no 
longer applies.

II. Provisions of the Proposed Rule, Summary of and Responses to Public 
Comments, and Provisions of the Final Regulations

    In response to the publication of the February 2020 proposed rule, 
we received approximately 66 timely pieces of correspondence. Contained 
within these 66 pieces of correspondence were approximately 810 
discrete comments concerning the extension of the CJR model by 3 years, 
the CJR model episode of care definition, the target price calculation, 
the reconciliation process, the elimination of the 50 percent cap on 
gainsharing, the beneficiary notice requirements and discharge planning 
notice, program waivers, the appeals process, evaluation, and 
regulatory impact. Additionally, we received many comments regarding 
our request for comment on new LEJR focused models that would include 
ASCs. These comments were from groups representing medical societies, 
hospital associations, hospitals, and medical centers. The remaining 
comments were from individual physicians and individual commenters.
    We received several comments that were in general agreement with 
the proposed rule as well as several comments that were in general 
disagreement with the proposed rule. Summaries of these comments and 
our responses are discussed later in this section. Finally, we received 
several comments that are considered out of scope. Although comments 
that are out of the scope of this rule are not addressed with the 
policy responses in this final rule, we are taking each

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comment into consideration and may address these comments in future 
rulemaking as warranted. Summaries of the public comments that are 
within the scope of the proposed rule and our responses to those public 
comments are set forth in the various sections of this final rule under 
the appropriate heading.
    Comment: A commenter stated that the extension of the CJR model 
continues to raise concerns about CMS' authority to implement a 
mandatory model, contending that it is an unconstitutional delegation 
of legislative authority and unfairly targets one-fifth of hospitals 
and one type of procedure and medical specialty. Another commenter 
stated that after 5 years of mandatory participation in the CJR model, 
the extension provides CMS the opportunity to transition CJR to a 
voluntary model for PYs 6-8. The commenter contended that a mandatory 
requirement violates the Innovation Center's authority.
    Response: For the reasons we discussed in the CJR model's November 
2015 and the December 2017 final rules, we continue to believe that 
section 1115A of the Act and the Health and Human Services (HHS) 
Secretary's existing authority to operate the Medicare program 
authorize the CJR model, including an extension of its duration as well 
as its mandatory nature. Specifically, sections 1102 and 1871 of the 
Act give the Secretary the authority to implement regulations as 
necessary to administer Medicare, including testing these Medicare 
payment and service delivery models as was done in the November 2015 
and the December 2017 final rules.
    The extension we are finalizing in this final rule does not impose 
any permanent changes to the Medicare program; rather, as discussed 
elsewhere in this rule, we are extending the performance period of 
model test in order to evaluate the impact of changes to the model that 
address changes in program payment policy and national care delivery 
patterns. This authority also allows the Secretary to test different 
methods for delivering services under Medicare to determine the 
effectiveness of these methods. We disagree with the commenter that 
contended that PYs 6 to 8 should be voluntary and that mandatory 
participation in the extension violates the Innovation Center's 
authority. As outlined in the CJR model November 2015 final rule, we 
believe that both section 1115A of the Act and the Secretary's existing 
authority to operate the Medicare program authorize the CJR model 
extension as we have proposed and are finalizing in this final rule. 
Section 1115A of the Act authorizes the Secretary to test payment and 
service delivery models intended to reduce Medicare expenditures while 
preserving or enhancing quality. The statute does not require that 
models be voluntary, but rather gives the Secretary broad discretion to 
design and test models that meet certain requirements as to spending 
and quality. Under this authority, re-evaluation of policies and 
programs, as well as revisions through rulemaking, are within an 
agency's discretion. Accordingly, the agency has authority to modify a 
mandatory model, as was done in the December 2017 final rule.
    As further discussed in section II.D.2. of this final rule, 
narrowing participation for hospitals in the 34 mandatory MSAs during 
the 3-year extension will allow CMS to minimize selection bias while 
evaluating the impact of the changes in this rule. Additionally, the 
cost to evaluate the small voluntary arm of the model for PYs 6 through 
8 is costly relative to the information that would be gained from the 
small sample size. For these reasons, we decline to adopt the 
commenter's suggestion to make PYs 6 through 8 voluntary.
    Comment: A commenter stated that there exists a significant 
administrative and management burden for providers associated with 
participating in multiple bundled payment initiatives simultaneously 
(for example, those that participate in both the BPCI Advanced model 
and CJR model at the same time). This commenter stated that managing 
multiple bundles across both models subjects participants to two 
different sets of financial specifications, reporting, and other 
measures, which is resource intensive. The commenter urged CMS to 
consider this burden by better aligning requirements for its various 
episode-based payment initiatives, including CJR and BPCI Advanced. 
They stated a possible solution to the administrative challenges of 
participating in both BPCI Advanced and CJR is to allow CJR 
participants the ability to participate in the lower joint Clinical 
Episode under BPCI Advanced rather than being required to participate 
in CJR.
    Response: We acknowledge the commenter's suggestion to allow 
hospitals currently participating in both the CJR model and the BPCI 
Advanced model to participate in BPCI Advanced only going forward; 
however, we disagree that participation in both models at the same time 
creates too much burden on participant hospitals, because the CJR model 
consists of only one type of episode of care, LEJR. BPCI Advanced on 
the other hand has various types of clinical episodes, one of which is 
the Major Joint Replacement of the Lower Extremity (MJRLE). For 
practical purposes, LEJR and MJRLE are referring to the same type of 
episode composed of MS-DRGs 469 and 470. The BPCI Advanced 
Participation Agreement states that if a participant or, if applicable, 
a Downstream Episode Initiator (for example, an acute care hospital) is 
also participating in an Innovation Center model implemented via 
regulation, such as the CJR model, the participant will not be held 
accountable for any clinical episodes included in that model for 
purposes of BPCI Advanced. This means that any LEJR episodes that are 
triggered by a hospital participating in both BPCI Advanced and CJR 
models would be reconciled under the CJR model and not the BPCI 
Advanced model. This approach has helped reduce the risk of 
inconsistent requirements across the two initiatives, thereby reducing 
burden on participants participating in both initiatives.
    CJR participant hospitals have had several years of experience with 
LEJR episodes focusing on quality and efficiency in the CJR model. CMS 
believes that participant hospital experience in the CJR model should 
alleviate issues with operational burden since CMS provides educational 
resources through the CJR Learning System and CJR Connect to assist CJR 
participant hospitals with managing operational processes. Moreover, 
CMS is committed to providing guidance regarding the changes made in 
this final rule relative to the previous CJR model requirements and 
will continue to provide educational resources during the extension for 
model participants.
    Finally, we note that while the BPCI Advanced model and the CJR 
model differ in various ways, the broad goals of the models are the 
same: Improving quality of care while reducing overall costs during an 
episode of care. We believe it is reasonable for model participant 
hospitals in both models and Downstream Episode Initiators in the BPCI 
Advanced model to engage in care redesign strategies targeted at LEJR 
episodes, regardless of the model under which the LEJR episode is 
reconciled. As such, we are finalizing the extension under which 
certain CJR participant hospitals are required to continue to 
participate in the CJR model, even if they are concurrently 
participating in BPCI Advanced and accountable under BPCI Advanced for 
non-LEJR episodes.
    Comment: Another commenter expressed support for proposed policies

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that promote consistency across model years, support investment in 
quality of care, and reduce operational burdens for CJR participants. 
This commenter specifically stated that moving to one reconciliation 
period, retaining current quality measures and removing gainsharing 
caps under the CJR model will help minimize burden on hospitals 
participating in CJR and BPCI Advanced while increasing consistency 
between CJR and BPCI Advanced.
    Response: CMS agrees with the commenter and believes that our 
efforts to decrease operational burden, such as moving to one 
reconciliation period, retaining current quality measures and, as we 
discuss in section II.G. of this rule, eliminating the 50 percent 
gainsharing cap will help to improve consistency between both models 
(CJR and BPCI Advanced).
    Comment: Although several commenters expressed support for the 
model's increased focus on decreasing costs, MedPAC argued that the 
proposed changes do not go far enough to generate savings for the 
Medicare program after accounting for reconciliation payments to 
providers. MedPAC suggested that the model be expanded nationally to 
help improve cost savings and improve Medicare's sustainability. MedPAC 
stated that evidence shows these changes would generate more savings 
for the model if it was expanded nationwide to increase the number of 
participant hospitals.
    Response: We appreciate this comment, but disagree that this model 
needs to be expanded nationwide for PY6 through PY8. Section 1115A(c) 
of the Act authorizes the HHS Secretary to expand a model, but only 
after taking into consideration the evaluation and after certain 
findings that CMS has not yet made. The model is still being evaluated 
for its ability to generate cost savings.
    Comment: Multiple commenters expressed their support for CMS' 
efforts to incentivize coordinated care and improve APMs. The 
improvements mentioned in these comments range from improved cost 
savings, quality measures, and outcomes for Medicare beneficiaries. A 
large number of commenters discussed their support for these listed 
goals and many others stated it as the primary reason for supporting 
this final rule. Other commenters expressed the need to continue to 
improve these areas and other areas of healthcare delivery.
    Response: We acknowledge and appreciate the commenters' remarks.
    Comment: Although several commenters expressed support for the 
changes to the CJR model, they listed several recommendations for CMS 
to consider when developing models in the future. A few commenters 
listed that there should be an increased focus on cost savings in 
future models. Although no specific adjustments were suggested, the 
commenters believed that the Innovation Center should prioritize cost 
savings more to improve the long term sustainability of the Medicare 
program.
    A significant portion of the commenters also discussed other areas 
of improvements for current and future models. Their suggestions 
included expanding the scope of the models to include services not just 
confined to services that are paid for by Medicare, allowing providers 
besides hospitals and physicians to lead models, and increasing 
financial incentives.
    Response: We thank the commenters for taking the time to provide 
input on future models. As the Innovation Center continues to develop 
more models we are always willing to accept input from various sources.

A. Episode Definition

1. Background
    The CJR model began on April 1, 2016. The CJR model is currently in 
its fifth performance year. The fifth performance year, which was 
extended to include all episodes ending on or after January 1, 2020 and 
on or before September 30, 2021, would necessarily incorporate episodes 
that began before January 1, 2020. As previously discussed in section 
I.C. of this final rule, the CJR model was created to bundle care for 
beneficiaries of Medicare Part A and Part B undergoing LEJR procedures, 
and in so doing, to decrease the cost and improve the quality of that 
care (80 FR 73274).
    When the CJR model was initially established in the November 2015 
final rule, the LEJR procedures on which the model is focused, 
specifically, those procedures for TKA, THA, and Total Ankle 
Replacement (TAR), were all listed on the IPO list. This meant that 
Medicare would only pay hospitals for these procedures when they were 
performed in the inpatient setting and billed through the Inpatient 
Prospective Payment System (IPPS). For this reason, CJR model episodes 
were defined to include inpatient procedures only. These TKA, THA, and 
TAR procedures all mapped to either Medicare Severity-Diagnosis Related 
Group (MS-DRG) 469 (Major Joint Replacement or Reattachment of Lower 
Extremity with Major Complications and/or Comorbidities (MCC)) or MS-
DRG 470 (Major Joint Replacement or Reattachment of Lower Extremity 
without MCC). Subsequently, in acknowledgement of the fact that the 
data analysis performed demonstrated TAR procedures are almost always 
more complex and expensive to perform than TKAs or THAs, CMS finalized 
a policy in the FY 2018 IPPS/LTCH PPS final rule (82 FR 38028 through 
38029) to ensure that inpatient TAR procedures would always map to the 
higher severity MS-DRG 469 and made corresponding changes to the MS-DRG 
titles (MS-DRG 469 became Major Hip and Knee Joint Replacement or 
Reattachment of Lower Extremity with MCC or Total Ankle Replacement; 
MS-DRG 470 became Major Hip and Knee Joint Replacement or Reattachment 
of Lower Extremity without MCC).
    In the FY 2021 IPPS/LTCH PPS final rule (85 FR 58491 through 
58502), CMS finalized two new MS-DRGs, 521 (Hip replacement with 
Principal Diagnosis of Hip Fracture, with MCC) and 522 (Hip replacement 
with Principal Diagnosis of Hip Fracture, without MCC) that encompassed 
a subset of hip replacement procedures that had previously mapped to 
MS-DRGs 469 and 470 regardless of whether or not a principal diagnosis 
of hip fracture was present. We modified the CJR model episode 
definition in the November 2020 IFC to include MS-DRGs 521 and 522, 
with discharges on or after October 1, 2020, in order to accommodate 
this change in MS-DRGs and ensure that the subset of hip replacement 
episodes that included a principal diagnosis of hip fracture was not 
dropped from the CJR model during PY 5.
    When the TKA procedure described by Current Procedural Terminology 
(CPT) Code 27447 was removed from the IPO list in the CY 2018 OPPS 
final rule (82 FR 59382) effective January 1, 2018, Medicare 
beneficiaries undergoing outpatient TKA procedures were, by default, 
excluded from the CJR model. When the change to the IPO list to remove 
TKA procedures was proposed, CJR participant hospitals raised concerns 
that the less complex TKA cases would move to the outpatient setting 
and the remaining inpatient population would represent a more complex 
and costly case mix than the population used to calculate the target 
price. As such, many commenters on the proposed OPPS 2018 rule (82 FR 
59384) expressed their concern that the target prices for the remaining 
inpatient CJR model episodes would be too low and would not reflect the 
shift in the inpatient patient population. While we noted the 
commenters' concerns, due to the lack of historical outpatient episode 
spending claims data on which to base a target price, we were not able 
to

[[Page 23501]]

recalculate target prices to reflect the movement of procedures from 
the inpatient to the outpatient setting at that time. We stated in the 
CY 2018 OPPS final rule with comment period (82 FR 59384) that we did 
not expect a significant volume of TKA cases that would previously have 
been performed in the hospital inpatient setting to shift to the 
hospital outpatient setting as a result of removing TKA from the IPO 
list. However, we also acknowledged that as providers' knowledge and 
experience in the delivery of hospital outpatient TKA treatment 
developed, there could be a greater migration of cases over time to the 
hospital outpatient setting. We further stated our intention to monitor 
the overall volume and intensity of TKA cases performed in the hospital 
outpatient department to determine whether any future refinements to 
the CJR model would be warranted.
    As of May 2019, since TKAs had been performed in the outpatient 
setting for the full calendar year of 2018, we had 1 full year of 
national spending data (including time for claims run out) with which 
to assess the early impact of TKAs being offered to Medicare 
beneficiaries in the outpatient setting. Our analysis of this 2018 
claims data showed that approximately 25 percent of TKAs were being 
performed in the outpatient setting, annually. These data also allowed 
us to explore spending differences between the least resource-intensive 
inpatient episodes and episodes based on an outpatient procedure. We 
used resource-intensity of inpatient episodes, as indicated by MS-DRG, 
as a proxy for identifying which patients may have been appropriate 
candidates for outpatient TKA, since the clinical information 
physicians use to make this judgment (for example, the patient's body 
mass index, smoking history, blood pressure among other clinical 
information) is not available on claims. Since we expected that the 
outpatient TKA procedures would only be performed on relatively healthy 
patients without complications or comorbidities and would have mapped 
to the MS-DRG 470 without hip fracture category had they been performed 
in the inpatient setting, we compared spending patterns between 
inpatient MS-DRG 470 without hip fracture episodes and outpatient TKA 
episodes (created using the same criteria as CJR model episodes, with 
the exception that they would have been triggered by the outpatient TKA 
[CPT code 27447]). Given that inpatient TKA procedures receive an MS-
DRG payment while outpatient TKA procedures are paid at a lower rate as 
part of payment for the Ambulatory Payment Classification (APC) to 
which they are assigned, we removed the payments associated with the 
episode initiating MS-DRG and/or CPT code for TKA, specifically CPT 
code 27447, and focused on the remaining episode costs for any post-
acute spending for these patients who we expected to be clinically 
similar. As we expected, post-acute spending patterns were highly 
similar between the inpatient MS-DRG 470/no fracture episodes and the 
outpatient TKA episodes, with average SNF costs of $9,229 and $9,252, 
and average home health costs of $3,070 and $3,074, respectively. 
Subsequent analysis of 2019 claims data showed similar results, with 
average SNF costs of $9,468 and $9,894, and average home health costs 
$3,060 and $3,029, respectively. This supported our belief that the 
outpatient TKA episodes were sufficiently comparable to MS-DRG 470/no 
fracture inpatient CJR model episodes that we should find a way to 
change the existing CJR model episode definition to encompass 
outpatient LEJR episodes as well as inpatient LEJR episodes.
2. Changes to Episode Definition To Include Outpatient TKA/THA
    Given stakeholders' interest in opportunities to treat LEJR 
patients in the outpatient setting as part of a bundled payment model, 
we explored ways to integrate outpatient TKA into the CJR model, as 
well as THA, in light of the change in the CY 2020 OPPS/Ambulatory 
Surgical Center (ASC) final rule to remove THA from the IPO list (84 FR 
61353). (We remind readers that the removal of any procedure from the 
IPO list does not mandate that all cases be performed on an outpatient 
basis. Rather, such removal allows for Medicare payment to be made to 
the hospital when the procedure is performed in the hospital outpatient 
department setting. The decision to admit a patient is a complex 
medical judgment that is made by the treating physician.)
    However, in the case of TKA and THA, if we continued to exclude 
outpatient TKAs and outpatient THAs from the CJR model and did not 
allow CJR participant hospitals the incentive to coordinate and improve 
care for these outpatient episodes, it is possible that this policy 
decision could create an unintentional financial incentive to perform a 
proportion of these procedures in a more expensive inpatient setting 
than would otherwise be medically necessary, thereby increasing costs 
to the Medicare program. Continuing to exclude outpatient TKAs and 
outpatient THAs would also potentially reduce the generalizability of 
future results from the CJR model evaluation, as CJR participant 
hospitals would be less comparable to control group non-CJR participant 
hospitals that did not have the same incentive to keep TKA and THA 
episodes in the inpatient setting, rather than moving appropriate 
episodes into the outpatient setting. Therefore, to ensure that our 
evaluation findings are as robust and generalizable as possible, we aim 
to incorporate outpatient LEJR procedures in such a way that we do not 
incentivize participants to choose a setting based on financial 
considerations rather than a given patient's particular level of need.
    One of CMS' recent goals has been to move toward site neutrality in 
pricing. For example, in the CY 2019 OPPS final rule (83 FR 58818) we 
finalized our policy to pay for clinic visits furnished at excepted 
off-campus provider-based hospital departments at an amount equal to 
the site-specific physician fee schedule payment rate for the clinic 
visit service furnished by a non-excepted off-campus provider-based 
hospital department. This goal was also reflected in the CY 2020 OPPS 
final rule (84 FR 61365), where we continued the 2-year phase-in of 
this site-neutral payment policy. Consistent with our goal for site 
neutrality, we do not want to create separate prices for inpatient and 
outpatient CJR model episodes. We also want to be consistent with the 
BPCI Advanced voluntary bundled payment model, which offers a site-
neutral LEJR episode and began January 1, 2020. These considerations, 
in conjunction with our finding that post-acute care costs were 
markedly similar for inpatient short stay TKAs, identified as those DRG 
470 claims with lengths of stay of 2 or fewer days, and outpatient 
TKAs, with much of the difference in overall episode prices accounted 
for by the MS-DRG payment for inpatient episodes versus the outpatient 
procedure rate paid through OPPS, supported our belief that we could 
create a site-neutral episode that would include both outpatient TKAs 
and the least complicated, short stay inpatient TKAs, which would group 
to the MS-DRG 470 without hip fracture category. However, given the 
remaining difference in post-acute spending, as well as the higher 
amount paid by Medicare for an inpatient procedure billed under the 
IPPS as opposed to an outpatient procedure billed under the OPPS, we 
recognize that simply providing the same target price for both

[[Page 23502]]

inpatient TKA episodes and outpatient TKA episodes, based on historical 
spending for the two episode types blended together, would mean that 
the single blended target price could potentially underestimate 
spending on some inpatient episodes and likewise, could potentially 
overestimate spending on some outpatient episodes. This would 
theoretically average out across all MS-DRG 470 without hip fracture 
episodes at the regional level during reconciliation, but given the 
fact that hospitals' ratio of inpatient-to-outpatient cases will vary, 
we believe an additional episode-specific risk adjustment to the target 
price is needed to account for beneficiary-specific factors other than 
the presence of a hip fracture. We discuss our proposal to risk adjust 
episodes in more detail in section II.C.4. of this final rule. We 
believe that our episode-specific risk adjustment methodology will 
incentivize clinicians to continue performing LEJR procedures in the 
appropriate clinical setting, particularly since performing these 
procedures on sicker patients in the outpatient setting could increase 
the risk of post-acute complications and lead to higher overall episode 
spending.
    Therefore, beginning with our proposed PY6, we proposed to revise 
the definition of an episode of care in the CJR model to include 
permitted outpatient TKA/THA procedures. This revised definition would 
have applied to episodes initiated by an anchor procedure furnished on 
or after October 4, 2020, because the 90-day episode would end on or 
after January 1, 2021, which would have been the first day of PY6. We 
note that, due to the extension of PY5, the revised definition would 
now apply to episodes initiated by an anchor procedure furnished on or 
after July 4, 2021, because the 90-day episode would end on or after 
October 1, 2021. Further, we proposed to group the outpatient TKA 
procedures together with the MS-DRG 470 without hip fracture historical 
episodes in order to calculate a single, site-neutral target price for 
this category of episodes, given that spending on outpatient TKA 
episodes most closely resembles spending on MS-DRG 470 without hip 
fracture episodes. We proposed that prices for the other three 
categories (MS-DRG 469 with hip fracture, MS-DRG 469 without hip 
fracture, and MS-DRG 470 with hip fracture) would continue to be 
calculated based on historical inpatient episodes only (with the 
exception of outpatient THA with hip fracture, which we would expect to 
happen rarely if at all, as described in this section). Since MS-DRGs 
521 and 522 were introduced after the proposed rule was published, and 
subsequently incorporated into the CJR episode definition in the 
November 2020 IFC, effective as of October 1, 2020, we note that the 
comparable groupings using the updated MS-DRGs are as follows: MS-DRG 
469 without hip fracture is now MS-DRG 469, MS-DRG 469 with hip 
fracture is now MS-DRG 521, MS-DRG 470 without hip fracture is now MS-
DRG 470, and MS-DRG 470 with hip fracture is now MS-DRG 522.
    Since the proposal to remove THAs from the IPO list had recently 
been finalized at the time of our February 24, 2020 proposed rule, we 
also proposed to include outpatient THA procedures with MS-DRG 470 
episodes in order to calculate a target price. Although we did not have 
Medicare claims data for outpatient THA at that time, as we did for 
outpatient TKA, we noted that the costs for TKA and THA tend to be 
similar, which is why the inpatient procedures are priced together in 
MS-DRGs 469 and 470. Outpatient THAs have been assigned to the same 
Comprehensive Ambulatory Payment System (C-APC) 5115 (Level 5 
Musculoskeletal Procedure) as outpatient TKA (84 FR 61253). Since the 
display of the proposed rule, we were able to analyze episode spending 
for selected 2020 claims data for TKA and THA episodes performed in the 
hospital outpatient department. We examined average episode costs for 
episodes initiated between July 1 and September 30 of 2020. We chose 
the third quarter because volume better approximated pre-COVID-19 PHE 
levels than earlier quarters in 2020 when many outpatient TKA and THA 
procedures were suspended. Further, it was the most recent available 
quarter of data with completed 90-day episodes after allowing time for 
claims runout. We observed that average total costs for outpatient THA 
episodes ($14,925) and outpatient TKA episodes ($15,286) were quite 
similar.
    Therefore, we believed that the site-neutral MS-DRG 470 price that 
we proposed to calculate (which would be based on a blend of inpatient 
TKA, inpatient THA, outpatient TKA, and outpatient THA episodes) would 
also be appropriate for outpatient THA episodes. However, in the case 
of THA, we would include any outpatient THA episodes without hip 
fractures in the MS-DRG 470 without hip fracture (now MS-DRG 470) 
episode pricing and we would include any outpatient THA episodes with 
hip fractures in the MS-DRG 470 with hip fracture (now MS-DRG 522) 
episode pricing. Compared to TKAs, which we would not expect to be 
performed on an outpatient basis in the presence of a hip fracture due 
to the added complexity of treating the hip fracture while performing 
the TKA, we believe that THAs with hip fractures would be somewhat more 
likely to be performed on an outpatient basis, since the THA could be 
treatment for the hip fracture. We note that most hip fracture cases 
involving a THA surgery typically present emergently and involve an 
inpatient admission, so we anticipate that few, if any, outpatient THA 
cases will involve hip fractures. However, we acknowledge the 
possibility that medical advances in the next 3 years could cause this 
to change. Therefore, we believe it is appropriate to separate 
outpatient THA into with and without hip fracture episodes that would 
be grouped into MS-DRG 522 and MS-DRG 470 episodes, respectively, 
because we expect that spending for outpatient THA with hip fracture 
and without hip fracture episodes would resemble spending for MS-DRG 
522 and MS-DRG 470 episodes, respectively.
    Given that we proposed that outpatient TKA and THA could initiate 
CJR model episodes, we similarly proposed that an outpatient TKA or 
THA, if furnished at a participant hospital during an ongoing 90-day 
CJR model episode, would cancel the ongoing episode and initiate a new 
episode. When an episode is cancelled, this means that the services 
associated with the cancelled episode continue to be paid under 
Medicare FFS, but the cancelled episode is not included in the annual 
reconciliation calculation. This is consistent with our current policy 
that inpatient hospitalizations for MS-DRGs 469, 470, 521, or 522 that 
occur at a participating hospital during an ongoing CJR model episode 
cancel the ongoing episode and initiate a new episode. We proposed to 
extend that policy to outpatient TKA and THA episodes.
    In conclusion, an active CJR model episode initiated by a prior 
admission to an acute care hospital for DRG 469, 470, 521, or 522 would 
be cancelled, and a new CJR model episode would be initiated, if either 
an inpatient LEJR procedure or an outpatient TKA or THA were furnished 
to an eligible beneficiary at a participating hospital during the 
ongoing episode initiated by the first joint procedure hospitalization. 
Similarly, a CJR model episode initiated by a first anchor procedure 
(outpatient TKA or THA) would be cancelled, and a new CJR model episode 
would be initiated, if either an inpatient LEJR procedure or an 
outpatient TKA or THA were furnished to an eligible beneficiary at a 
participating hospital during the

[[Page 23503]]

ongoing episode initiated by the first anchor procedure.
    Since the publication of the February 24, 2020 proposed rule, CMS 
finalized phasing out the IPO list entirely over a 3-year period in the 
CY 2021 OPPS/ASC final rule with comment period (85 FR 85866 through 
86305). TAR was among the procedures removed from the IPO list for CY 
2021. This means that, as of January 2021, Medicare will pay each of 
the procedures included in the CJR model (TKA, THA, and TAR) when 
performed in an outpatient department of the hospital. Unlike THA and 
TKA, we do not expect that TAR will be widely performed in the hospital 
outpatient department. The procedure is much more complex than TKA or 
THA. In the absence of an MCC, both TKA and THA are typically paid 
through the less expensive MS-DRG 470, as discussed. However, Medicare 
always pays for TAR through the more expensive MS-DRG 469, in 
recognition of TAR's higher complexity and resource-intensity. We 
expect less complex patients to be eligible for treatment in the 
hospital outpatient department. Further, TAR is significantly less 
common than TKA and THA, comprising only 0.8 percent of all CJR 
episodes in 2020. For this reason, we are not incorporating outpatient 
TAR into the CJR episode definition. We will monitor data on TAR and 
consider future adjustments to the CJR episode definition, if 
warranted, through notice-and-comment rulemaking.
    The following is a summary of the comments received and our 
responses.
    Comment: Several commenters supported CMS' proposal to incorporate 
outpatient TKA and outpatient THA into the CJR model episode 
definition. A commenter stated they view this change as allowing the 
model to keep pace with the changing standards of care and clinical 
practices across the country. Multiple commenters stated that since CMS 
has authorized TKA and THA surgery to be performed in the outpatient 
hospital setting under the Medicare program, it is appropriate to 
include these procedures in the CJR model to encourage hospitals, 
physicians, and post-acute care providers to work together to improve 
the quality and coordination of care for patients in this setting. A 
commenter stated that they commended CMS for taking steps to align the 
CJR model with other value-based care initiatives, namely the BPCI 
Advanced model, which includes both inpatient and outpatient LEJR 
episodes. A commenter stated their agreement with our proposal to 
distinguish between outpatient THA cases with and without hip fracture, 
even though hip fracture cases involving THA surgery typically would 
involve an inpatient admission.
    Response: We appreciate the commenters' support for our proposal to 
revise the CJR model episode definition to include outpatient TKA and 
THA. We agree that this change will encourage increased quality of care 
and care coordination across a wider range of treatment settings. We 
further appreciate that commenters supported our effort to better align 
the CJR model with BPCI Advanced, as well as our decision to 
distinguish between outpatient THA with and without hip fracture.
    Comment: Multiple commenters recommended that CMS add a definition 
at Sec.  510.2 to specify that for the CJR model purposes, ``outpatient 
setting'' means the hospital outpatient department (HOPD). These 
commenters pointed out that this would distinguish HOPDs from other 
alternatives to inpatient care, such as an ASC.
    Response: We appreciate the commenters' suggestion, which we 
believe pertains to the definition of anchor procedure and its use of 
the term ``outpatient setting.'' We agree that the definition should be 
revised to clarify that by outpatient setting we mean a hospital 
outpatient department. We have made this change to the regulatory 
definition of ``anchor procedure'' at Sec.  510.2.
    Comment: A few commenters requested clarification as to how 
outpatient episodes and their associated costs will be identified. A 
commenter asked whether outpatient episodes would be identified based 
on the presence of CPT codes 27447 or 27130 on the claim. Another 
commenter noted that when a patient has outpatient surgery for joint 
replacement, they often spend a night in the hospital and are seen by 
other physicians, such as hospitalists, to manage medical issues. The 
commenter asked whether the services of these physicians, which would 
be billed to Part B using CPT codes 99201-99215, would be included in 
the bundle as costs. Another commenter requested clarification on 
whether the episode would begin on the day of surgery as reported on 
the claim form, and, given that the 3-day payment rule does not apply 
to outpatient procedures, whether any pre-operative services in the 3 
days prior to surgery would be included in the episode.
    Response: We appreciate the opportunity to provide clarifying 
details as to how outpatient TKA and THA episodes will be determined. 
Outpatient episodes will be identified by the presence of CPT codes 
27447 (TKA) or 27130 (THA) on an outpatient claim (specifically, a 
hospital's institutional claim for an outpatient TKA or THA billed 
through the OPPS). The episode begins on the day of the anchor 
procedure, which will also be considered the discharge date, (that is, 
it would be considered day 1 of the 90-day post-acute portion of the 
episode).
    In response to the commenter who referenced the 3-day payment rule 
(75 FR 50346), we note that this refers to the policy that states that 
a hospital (or an entity that is wholly owned or wholly operated by the 
hospital) must include on the claim for a beneficiary's inpatient stay, 
the diagnoses, procedures, and charges for all outpatient diagnostic 
services and admission-related outpatient non-diagnostic services that 
are furnished to the beneficiary during the 3-day (or 1-day) payment 
window. This means that such services are included under the MS-DRG 
payment, rather than billed separately, and in that way are reflected 
in the CJR model episode, even if they occur prior to the day of 
inpatient admission. We note that outpatient CJR model episodes will 
not have a comparable policy, so services provided prior to the day of 
the outpatient procedure will not be included in episode costs.
    Our decision not to include a 3-day lookback for outpatient 
episodes is consistent with our decision in the November 2015 final 
rule to only include Part B claims for services on or after the date of 
admission in inpatient episode spending (80 FR 73315). Although we 
acknowledged at that time that there may be opportunities for care 
redesign and improved efficiency prior to the inpatient 
hospitalization, we stated our belief that these opportunities would be 
limited for an episode payment model focused on a surgical procedure 
and the associated recovery, as opposed to a different type of model 
that focused on decision-making and management of an underlying 
clinical condition itself (such as osteoarthritis). We also stated our 
belief that beginning the episode too far in advance of the LEJR 
surgery would make it difficult to avoid bundling unrelated items, and 
starting the episode prior to hospital admission would be more likely 
to encompass costs that vary widely among beneficiaries, which would 
make the episode more difficult to price appropriately (80 FR 73316).
    However, since TKA was removed from the IPO list in 2018, we have 
discovered that the Part B claim for the surgeon's professional 
services is occasionally missing from CJR episode spending for 
inpatient episodes

[[Page 23504]]

associated with an inpatient TKA procedure. This was an extremely rare 
occurrence when all LEJR procedures were performed on an inpatient 
basis (0.2 percent of episodes in both PY1 and PY2), because the LEJR 
procedure would always be associated with an inpatient stay with a date 
of admission on or before the procedure itself, since it would not be 
paid for by Medicare if performed in the outpatient setting. Now that 
LEJR procedures can be performed on either an inpatient or outpatient 
basis, meaning that the LEJR procedure itself may or may not be 
associated with an inpatient stay, the decision of whether or not to 
admit the patient for an inpatient stay does not necessarily need to be 
made on the day of the procedure.
    Since the removal of TKA from the IPO list, the frequency of CJR 
episodes (all of which, by definition, have been associated with an 
inpatient stay) that have been missing the surgeon's Part B 
professional claim has increased ten-fold (2.1 percent in PY3, and 2.8 
percent in PY4). This omission has occurred because the date of the 
procedure was prior to the date of the inpatient admission. We believe 
that in most of these cases, the surgery is performed on an outpatient 
basis under the assumption that the patient will not require an 
inpatient admission, but the patient is subsequently determined to need 
more acute care and is admitted as an inpatient within 3 days. In such 
a case, the institutional charge for the procedure, which originally 
would have been billed through the OPPS, would instead be billed 
through the IPPS. Had the subsequent inpatient admission not occurred, 
the procedure would have been considered an outpatient procedure for 
purposes of the CJR episode definition, and it would not have triggered 
a CJR episode. However, as a result of the subsequent inpatient 
admission, the procedure would instead be associated with an 
institutional charge billed through the IPPS, and therefore would 
trigger a CJR episode even though the procedure itself predated the 
inpatient admission.
    In the case of the subsequent inpatient admission after an 
outpatient LEJR procedure, most costs associated with the inpatient 
hospitalization would still be included in the MS-DRG payment due to 
the 3-day lookback period that already applies to inpatient 
hospitalizations, but the surgeon's professional claim (dated within 3 
days prior to the date of admission in 98 percent of these cases), 
would not be included in CJR episode spending because it would be 
billed as a Part B professional claim with a date of service prior to 
the date of the inpatient admission. Given our clearly stated intention 
to include claims for Part B professional services on the date of the 
surgery, we are making a technical change to the services included in a 
CJR episode, which in PYs 6-8 will begin on the date of admission for 
episodes initiated by an inpatient hospitalization (that is, an anchor 
hospitalization) or the date of the procedure for episodes initiated by 
an outpatient procedure (that is, an anchor procedure). This change 
will only apply to episodes initiated by an inpatient anchor 
hospitalization that do not include a surgeon's Part B professional 
claim for the LEJR procedure itself because the procedure occurred 
prior to the inpatient admission date.
    Beginning in PY6, in these cases only, we will perform a 3-day 
lookback to identify the surgeon's Part B professional claim and 
include it in episode spending. The episode start date will continue to 
be the date of admission on the IPPS claim associated with the anchor 
hospitalization that triggered the episode, rather than the procedure 
itself being treated as an anchor procedure and triggering the episode. 
To clarify the fact that the procedure would not be considered an 
anchor procedure in this situation, we have amended the definition of 
anchor hospitalization to specify that an anchor hospitalization would 
be initiated upon admission to an inpatient hospital stay within 3 days 
after an outpatient TKA or outpatient THA procedure and amended the 
definition of anchor procedure to specifically exclude such situations. 
The 3-day lookback policy for episodes triggered by an anchor 
hospitalization that are missing the surgeon's Part B professional 
claim will be specifically limited to the surgeon's Part B professional 
claim, such that no other claims during that 3-day period prior to the 
date of the inpatient admission will be pulled into the episode 
spending total. We have made this technical change to the regulation 
text at Sec.  510.200(b)(15).
    Comment: A commenter requested that we provide outpatient cost data 
to participant hospitals, as participant hospitals currently do not 
have access to the full cost of care for Medicare beneficiaries in the 
outpatient setting. They stated their belief that this information 
would help providers better understand beneficiaries' needs and how to 
meet those needs more cost effectively, whereas without the cost data, 
it would be difficult to understand the impact of the variable case mix 
on cost.
    Response: We agree that as a result of the revised episode 
definition, participant hospitals will need additional data for 
episodes that are initiated in the outpatient setting to facilitate 
their success in the CJR model. We will provide participant hospitals 
with monthly claims data for outpatient episodes that are comparable to 
what they currently receive for inpatient episodes. They will have 
timely access to claims data across all treatment settings included in 
the episodes, which will allow them to better understand beneficiaries' 
needs and how to meet those needs in the most cost effective way while 
maintaining care quality.
    Comment: Multiple commenters supported the proposal to create a 
site-neutral target price for inpatient and outpatient episodes. MedPAC 
stated that it supports adding LEJR procedures performed in outpatient 
hospital departments to the CJR model and setting site-neutral target 
prices for inpatient and outpatient episodes. MedPAC further stated 
that it agrees with CMS's proposal to base the target price for MS-DRG 
470 without hip fracture on a blend of historic spending for outpatient 
TKA episodes, outpatient THA episodes without hip fracture, and 
inpatient episodes for MS-DRG 470 without hip fracture because of the 
cost similarity of these episodes. Another commenter stated their 
belief that the proposed addition of outpatient procedures as a 
blended, site-neutral payment adequately captures episodes that are 
triggered in hospital-based outpatient departments, and that the 
addition of hospital outpatient procedures to the CJR model will aid 
CMS in driving efficiency in these settings. Another commenter stated 
their support for including outpatient procedures in the CJR model 
because it decreases the incentive to perform these procedures in the 
inpatient setting unnecessarily on otherwise healthy patients who lack 
complications or comorbidities, particularly in light of the similar 
cost considerations for post-acute care for both inpatient and 
outpatient procedures.
    Response: We appreciate the commenters' support for our creation of 
a site-neutral target price for inpatient and outpatient episodes.
    Comment: A commenter stated that they support site neutral target 
prices, but stated that this support was contingent on the quality of 
the surgical care and medically necessary follow-up rehabilitation care 
being maintained. Another commenter similarly stated that they support 
site neutral target prices, but expressed concern about the potential 
for a site neutral inpatient/

[[Page 23505]]

outpatient target price to drive higher risk patients to the lower cost 
outpatient setting. This commenter stated their concern that hospitals 
would overrule the decision-making of the physician and patient as to 
the most appropriate setting for the patient's surgery, such that a 
patient who, based on the clinician's judgment and/or the patient's 
preference, should receive a TKA or THA on an inpatient basis would 
instead receive the procedure on an outpatient basis. They urged CMS to 
regularly analyze utilization data and monitor for significant shifts 
in procedure setting and/or negative outcomes, and make results from 
these analyses publicly available through peer-reviewed literature and 
CMMI model evaluation reports.
    Response: We appreciate the commenters' support for our creation of 
a site-neutral target price for inpatient and outpatient episodes. We 
also acknowledge their concern about unintended consequences, where a 
provider might choose to steer certain patients to the outpatient 
setting when it is not in the best interest of, or is against the 
preferences of, the patient. We note that, since the IPO list was 
established in 2000, we have consistently stated that regardless of how 
a procedure is classified for purposes of payment, we expect that in 
every case the surgeon and the hospital will assess the risk of a 
procedure or service to the individual patient, taking site of service 
into account, and will act in that patient's best interest (65 FR 
18456). We have reiterated this sentiment in rulemaking several times 
over the years, including the removal of TKA from the IPO list in the 
CY 2018 OPPS/ASC final rule with comment period (82 FR 59383), removing 
THA from the IPO list in the CY 2020 OPPS/ASC final rule with comment 
period (84 FR 61142), and most recently in phasing out the IPO list in 
the CY 2021 OPPS/ASC final rule with comment period (85 FR 86083). The 
decision regarding the most appropriate care setting for a given 
surgical procedure is a complex medical judgment made by the physician 
based on the beneficiary's individual clinical needs and preferences 
and on the general coverage rules requiring that any procedure be 
reasonable and necessary (84 FR 61354). We expect hospitals to respect 
the decision of the physician and patient.
    Additionally, as we stated in the February 2020 proposed rule, a 
provider who treats a patient in the outpatient setting when the 
inpatient setting would be more appropriate risks the patient 
developing complications and requiring costlier care to recover from 
those complications than would have been necessary if the patient's 
procedure had taken place in the more appropriate inpatient setting. 
Our episode-level risk adjustment (described in Section II.C.4) is 
designed to incentivize the provision of care in the appropriate 
setting, by increasing the episode target price for beneficiaries who 
are likely to require more resources and be costlier to treat, due to 
the complexity of their condition, and lowering the episode target 
price for beneficiaries who are likely to require a lower degree of 
care. We believe this methodology will greatly reduce the likelihood of 
a participant treating a beneficiary in a setting that is not 
concordant with the beneficiary's actual care needs.
    Finally, we will continue the monitoring practices that we have had 
in place throughout the CJR model to identify patterns of inappropriate 
care, which includes monitoring the proportion of patients who are 
treated in the outpatient setting by CJR participant hospitals in 
comparison to non-CJR participant hospitals. If we see that certain 
hospitals are treating patients in the outpatient setting at a rate 
that is different from their peers and cannot be explained by aspects 
of the hospital's patient population such as average age, count of CMS-
HCC conditions, and area-level socioeconomic factors, then we have 
multiple options for remediation as described in the November 2015 
final rule, which include requiring the participant hospital to develop 
a corrective action plan and reducing or eliminating a participant 
hospital's reconciliation payment (Sec.  510.410(b)(2)). We will also 
continue to share changes in practice patterns and trends we identify 
through evaluation reports and other means.
    Comment: Many commenters stated that they do not believe the 
episode definition should be changed at this point in time. They 
suggested either postponing the inclusion of outpatient episodes in the 
CJR model, or maintaining separate cost target categories for 
outpatient TKA and outpatient THA, rather than grouping them with DRG 
470. A few commenters expressed their concern that the safety of 
outpatient TKA and outpatient THA has not been established, and that 
CMS does not have enough experience with these episodes to incorporate 
them into the CJR model.
    Response: We acknowledge that, at the time that the February 2020 
proposed rule was published, both TKA and THA had been removed from the 
IPO list relatively recently, and we appreciate the commenters' 
concerns about patient safety. However, the extension of PY5 through 
September 30, 2021 means that by the time outpatient TKA and outpatient 
THA episodes are incorporated into the CJR model, participant hospitals 
will have had just under 4 calendar years of experience with outpatient 
TKA and just under 2 calendar years of experience with outpatient THA. 
Prior to CMS' recommendation to postpone elective surgeries between 
March and April of 2020 due to COVID-19 PHE, the percentage of 
outpatient TKA episodes had been steadily increasing since outpatient 
TKA was removed from the IPO list as of January 2018. In February 2020, 
43 percent of TKA procedures at CJR participant hospitals were 
performed in the outpatient setting. This suggests that hospitals had 
the experience of treating a substantial number of outpatient TKA 
patients during the two years prior to the temporary suspension of 
elective surgeries. The number of outpatient THA procedures beginning 
in January 2020 showed a similar pattern to outpatient TKA, suggesting 
that hospitals had a similar level of confidence in their ability to 
manage outpatient THA patients. After a steep decline in outpatient 
TKA/THA volume during the months of March and April of 2020, elective 
surgeries resumed in May and showed monthly volume increases through 
the summer of 2020, although we acknowledge that some hospitals have 
since chosen to postpone elective surgeries for varying periods of time 
due to local COVID-19 resurgences. Given the degree to which we expect 
outpatient TKA and outpatient THA to return to their previous volumes 
as a result of decreased COVID-19 hospitalizations and due to the 
national COVID-19 vaccination campaign currently underway, we believe 
that by the time PY6 begins and outpatient TKA and outpatient THA are 
incorporated into the CJR episode definition, hospitals will have had 
the opportunity to perform enough of these outpatient procedures to 
have gained considerable expertise in their outpatient episode 
management.
    Regarding patient safety, we note that State and local regulations, 
accreditation requirements, hospital conditions of participation 
(CoPs), medical malpractice laws, and other CMS initiatives will 
continue to ensure the safety of beneficiaries receiving TKA or THA in 
both the inpatient and outpatient settings, so we believe that further 
delay is not necessary before incorporating outpatient TKA and THA into 
the CJR model episode definition.

[[Page 23506]]

In particular, the CoPs are regulations that are focused by statute 
almost exclusively on protecting the health and safety of all patients 
and are intended to be the baseline health and safety requirements on 
which hospitals, accreditation organizations, States and localities, 
and professional organizations can add and build upon with more 
specific and more stringent requirements. We note that the CoPs already 
require hospitals to be in compliance with applicable Federal laws 
related to the health and safety of patients (42 CFR 482.11). 
Additionally, there are numerous regulatory standards and provisions in 
the hospital CoPs at 42 CFR 482 that provide extensive patient 
safeguards and that provide enough room and flexibility so as to ensure 
that hospitals can follow nationally recognized standards of practice 
and of care where they are applicable and can adapt if those standards 
change over time through innovative new practices. We discussed these 
patient safeguards in more detail in the CY 2021 OPPS/ASC final rule 
with comment period (85 FR 86084).
    As indicated in the 2020 Quality Strategy, CMS has continued to 
develop safety measures and tools, like the Outpatient and Ambulatory 
Surgery Consumer Assessment of Healthcare Providers and Systems Survey 
(OMB Control Number: 0938-1240), to help determine the safety and 
quality of the performance of procedures in the outpatient setting, to 
alleviate concerns about the safety and quality of more varied, complex 
procedures performed in the outpatient setting. Additionally, if a 
beneficiary communicates a concern about the quality of their care to 
the Medicare Beneficiary Ombudsman (MBO), that communication will be 
relayed to the beneficiary's CMS Regional Office and the CJR team for 
further investigation. The CJR team also regularly monitors episode 
claims data to identify patterns that suggest inappropriate practices 
on the part of a CJR participant hospital. Therefore, given CMS' 
developing ability to measure the safety of procedures performed in the 
outpatient setting and to monitor the quality of care, we do not 
believe a delay in incorporating outpatient TKA and THA into CJR is 
needed.
    Comment: Multiple commenters stated their concern about introducing 
multiple changes to the CJR model at this time, in light of the COVID-
19 PHE. They stated that the introduction of outpatient episodes with a 
blended inpatient/outpatient target price and new risk adjustment 
methodology was too much change for participant hospitals to adapt to 
while they are still dealing with the impacts of the COVID-19 PHE.
    Response: We appreciate the commenters' concerns, and we recognize 
that the COVID-19 PHE has created many challenges for participant 
hospitals and the healthcare system as a whole. In order to support 
continuity of model operations and ensure that participants would not 
unfairly suffer financial consequences of the COVID-19 PHE due to their 
participation in the CJR model, we first extended PY5 by 3 months in 
the April 2020 IFC. Many commenters on the April 2020 IFC requested 
that PY5 be further extended, for a total of a 12-month extension. In 
the November 2020 IFC we extended PY5 by an additional 6 months for a 
total extension of 9 months. Although not the full 12-month extension 
that commenters requested, we believe that this 9-month extension will 
provide participant hospitals adequate time to adapt to both the COVID-
19 PHE and TKA/THAs being removed from the IPO list. We reiterate that 
the extension of PY5 through September 30, 2021 means that by the time 
outpatient TKA and outpatient THA episodes are incorporated into the 
CJR model, participant hospitals will have had just under four calendar 
years of experience with outpatient TKA and just under 2 calendar years 
of experience with outpatient THA. As stated previously, we expect 
outpatient TKA and outpatient THA to return to previous volumes as a 
result of decreased COVID-19 hospitalizations and due to the national 
COVID-19 vaccination campaign currently underway by the time PY6 begins 
and outpatient TKA and outpatient THA are incorporated into the CJR 
episode definition. In February of 2020, there were approximately 
13,000 TKA and 5,500 THA performed in the outpatient setting. Although 
the number decreased dramatically in March 2020, by June 2020 the 
frequency of outpatient TKA had nearly returned to pre-COVID 19 PHE 
levels and outpatient THA exceeded previous levels, with approximately 
11,500 TKA and 6,500 THA performed in the outpatient setting that 
month. Therefore we believe that hospitals will have had the 
opportunity to perform enough of these outpatient procedures to have 
gained considerable expertise in their outpatient episode management 
and they will be able to adapt to the changes to the CJR model when 
they are introduced for PY6.
    Comment: A commenter stated that, while they understood that CMS 
cited its primary reason for the extension was to test the impact of 
Medicare paying for TKA and THA in the hospital outpatient setting, 
there are a number of factors that would prove problematic for testing 
that episode under the CJR model. For example, they stated their belief 
that it would be difficult, if not impossible, to generalize any future 
findings from the CJR model that occur over the next several years, as 
these evaluation results would be confounded by the impact of the 
COVID-19 PHE.
    Response: We acknowledge the commenter's concern about the 
generalizability of results due to the COVID-19 PHE. However, given the 
extension of PY5 through September 30, 2021 and the expectation that 
COVID-19's impact on participant hospitals will be greatly mitigated by 
an aggressive COVID-19 vaccination initiative through the first 3 
quarters of 2021, we believe that the experience of CJR participant 
hospitals under the modified methodology will largely reflect the post-
COVID-19 realities of the healthcare system that will continue for the 
foreseeable future. Therefore we believe that the results will be 
sufficiently generalizable to test the impact of CJR methodology on 
outpatient TKA and outpatient THA episodes.
    Comment: Multiple commenters suggested that CMS create separate 
cost target categories for outpatient TKA and outpatient THA in the CJR 
model due to their assertion that the episode-level risk adjustment 
methodology would not sufficiently mitigate the cost differential 
between inpatient and outpatient episodes. They pointed out that 
patients who fall into a low risk category may prefer to be treated in 
the inpatient setting for a variety of reasons that are not captured in 
the risk adjustment. Other commenters stated their concern that some 
hospitals may be disadvantaged by a blended target price due to factors 
beyond the hospital's control, which are not accounted for in the risk 
adjustment methodology. A commenter pointed out that, while the number 
of TKAs and THAs performed in the outpatient setting has increased 
overall, the increase varies widely across hospitals, driven by a 
number of factors including beneficiary demographics and prevalence of 
comorbidities in the local market, surgeon experience and preferences, 
the capabilities of hospitals of various sizes, the availability of 
multidisciplinary care coordination and discharge planning teams, the 
types of post-acute care resources present within a region, population 
dispersion, and rurality within a hospital's referral region.
    Response: We acknowledge the commenters' concerns, but we note that

[[Page 23507]]

the episode level risk adjustment methodology is designed specifically 
to address the concern that some hospitals may perform a higher 
percentage of inpatient episodes due to the age, health, and 
socioeconomic status of the surrounding patient population. For 
instance, if the patient population for a given participant hospital 
tends to be older than that of other participant hospitals, the episode 
level risk adjustment would adjust the target price upward (assuming 
the risk adjustment coefficient were greater than 1), such that a 
participant hospital with an older population would have a greater 
increase in their aggregate target price due to risk adjustment than 
would a participant hospital with a younger population. We further note 
that, although we originally did not propose to include a variable 
related to socioeconomic status, in response to comments and our 
subsequent analyses, we are including dual-eligibility in the final 
risk adjustment methodology as a proxy for socioeconomic status, along 
with the previously proposed age group and CJR HCC count (described in 
section II.C.4 of this final rule). Participant hospitals that treat an 
older, sicker, or socioeconomically disadvantaged population will have 
their episode target prices adjusted upwards accordingly. Our decision 
to remove rural and low-volume hospitals from the extension will also 
reduce the variation between the remaining participant hospitals in 
PY6-8 in terms of size, population dispersion, and rurality within 
participant hospitals' referral regions.
    Comment: A few commenters stated concerns related to the 
calculations underlying our proposed changes to the target price 
calculation methodology and the information we provided in the proposed 
rule to allow commenters to understand and comment on our proposed 
methodology. A commenter stated their concern that CMS did not provide 
further information about how we analyzed the impact of the mix of 
inpatient versus outpatient procedures on site-neutral pricing. This 
commenter also stated their belief that CMS's proposal to revise the 
existing MS-DRG 470 without hip fracture pricing category to include 
both outpatient TKA and outpatient THA appeared to be based on limited 
data and simulated cost comparisons, and that CMS did not provide an 
adequate description of the methodology or access to data for 
independent analysis. Another commenter stated that, due to the fact 
that MS-DRG weights are calculated using data with a 2-year lag, the 
current MS-DRG 470 payment is based on costs for an overall healthier 
pool of patients, because healthier patients had not yet begun shifting 
to the outpatient setting at that time. This commenter stated their 
belief that the payment for MS-DRG 470 was therefore inadequate and 
should not be used as the basis for target prices in a mandatory model.
    Response: We disagree with commenters who stated that the analyses 
underlying our decision to calculate a blended inpatient/outpatient 
target price were insufficient due to the use of simulated episode 
data. Although we acknowledge that actual episode data are preferable, 
we believe that multiple aspects of our target price methodology (for 
example, the use of the most recent 1 year of baseline data, risk 
adjustment, and the retrospective market trend adjustment) will allow 
for the adjustment of target prices to the extent that data from actual 
outpatient episodes (with TKA beginning in 2018 and THA beginning in 
2020) differ from the simulated episode data we used to design the 
methodology. We built this flexibility into the target price 
methodology specifically to address the fact that patterns of care and 
spending can evolve over time. We note that we did not calculate a 
specific factor to determine the impact of site on the target price, 
because outpatient episodes constituted a relatively small percentage 
of all TKA/THAs at the time we performed our analyses, and we could not 
assume that such a factor would give a meaningful estimate of the 
impact of site on the target price over time. We further note that we 
have updated our analyses using 2019 claims data, which include a full 
year of actual outpatient TKA episodes, and the results have been 
consistent with those we reported based on simulated episodes from 
previous years (see Tables 3a and 4a in section II.C.4 of this final 
rule). For more specific data on the blended target price, we point 
commenters to Table 2a of this final rule in section II.B.2. of this 
final rule for preliminary regional target prices for PY6. We 
acknowledge that changes to the Medicare policies determining payment 
for TKAs/THAs have resulted in shifts in site of service that could 
impact the cost of episodes, but we point out that the change from 
using 3 years of data to 1 year of data as a baseline for target prices 
and our retrospective market trend adjustment are both designed to 
allow target prices to better reflect changes in both practice patterns 
and Medicare payment systems. Finally, we note that the fact that we 
received substantive comments on the blended target price methodology 
from the majority of commenters on this topic indicates that we 
provided an adequate level of information to enable providers to 
evaluate the methodology. Therefore we believe that we described our 
data analyses adequately and that our use of simulated episode data, 
with results later confirmed by analyses of actual episode data, was an 
appropriate basis for our decision to calculate a blended target price.
    Comment: Multiple commenters requested that CMS issue a standard 
set of criteria to help participants determine which patients are 
suitable candidates for outpatient surgery. A commenter stated his or 
her belief that, taking into consideration the proper patient 
assignment and providers' clinical judgment, it would be beneficial to 
many CJR participant hospitals if CMS provided directional criteria for 
outpatient THA/TKA versus inpatient total joint replacements. They 
stated that a standard set of criteria would benefit many hospitals 
when it comes to the clinical pathways adoption rate. Other commenters 
pointed to the October 2018 ``Position Statement on Outpatient Joint 
Replacement,'' jointly issued by the American Association of Hip and 
Knee Surgeons (AAHKS), the American Academy of Orthopaedic Surgeons 
(AAOS), The Hip Society, and The Knee Society, which includes 
recommendations for outpatient hip and knee arthroplasty procedures to 
guide hospitals, surgeons, and institutions in appropriate and safe 
patient care. These commenters urged CMS to work with these societies 
to operationalize their recommendations. Another commenter provided a 
list of medical and psychosocial exclusion criteria that the commenter 
believes should be applied to outpatient TKA and THA episodes. A 
commenter suggested that CMS could provide guidance on predictive tools 
to inform discharge planning to facilitate surgeon/hospital 
establishment of patient risk profiles. Another commenter requested 
detailed guidance on the application of the 2-midnight rule to TKA and 
THA procedures.
    Response: We acknowledge these commenters' request, but we note 
that CMS does not make clinical recommendations for care. We believe 
that the treating clinician, in partnership with the patient, is best 
suited to make the judgment of the appropriate clinical setting. Other 
government agencies, such as the Agency for Healthcare Research and 
Quality (AHRQ), or professional societies may provide resources to help 
guide clinical decisions. For guidance on the application of the 2-
midnight rule to TKA and THA procedures we

[[Page 23508]]

refer commenters to the CY 2020 OPPS/ASC rule (84 FR 61363 through 
61365).
    Final Decision: After consideration of the public comments 
received, we are finalizing our proposal to include outpatient TKA and 
THA in the CJR model episode definition with a blended inpatient/
outpatient target price. (The methodology for calculating this blended 
target price is discussed in section II.B. of this final rule.)
3. Freezing Hip Fracture List and Episode Exclusions List
    In the November 2015 final rule we finalized our proposal to 
establish a sub-regulatory process to update both the hip fracture list 
(indicating the International Classification of Diseases, 9th Revision, 
Clinical Modification (ICD-9-CM) and ICD-10-CM codes that would 
designate a hip fracture for purposes of risk adjustment in the 
baseline period and performance period, respectively (80 FR 73544) and 
the episode exclusions list (indicating which services would be 
considered unrelated to the episode, and therefore excluded from 
episode spending totals in both the baseline period and performance 
period) (80 FR 73305). At that time, Medicare had recently transitioned 
from the use of ICD-9-CM codes to ICD-10-CM codes (as of October 2015), 
and the ICD-10-CM code list was being expanded on an annual basis. For 
this reason, we finalized our proposal to update both the hip fracture 
list and the exclusions list without rulemaking on at least a yearly 
basis to reflect annual changes to ICD-CM coding, annual changes to the 
MS-DRGs under the IPPS, and any other issues that were brought to our 
attention by the public throughout the course of the model test (80 FR 
73305). Our first set of revisions, applicable as of October 1, 2016, 
added 40 additional codes within the M84 category to the original 1,152 
codes on the hip fracture list and 60 additional code categories to the 
original 574 code categories on the episode exclusions list.
    Now that Medicare has used the ICD-10-CM coding system for over 
five years, the rate of annual coding changes has stabilized, which has 
resulted in fewer, if any, changes to either the hip fracture or 
episode exclusions list in recent years of the CJR model. For FY 2018, 
the hip fracture list remained unchanged, while 28 categories were 
added to the episode exclusions list. For FY 2019, we did not identify 
any changes to the ICD-10-CM codes that would impact the hip fracture 
list or episode exclusions list, so they were not updated. We note that 
the introduction of the new MS-DRGs 521 and 522 is a different way for 
the IPPS grouper to assign an MS-DRG weight to a subset of existing 
ICD-10-CM codes to reflect a differential in the cost of the associated 
hospitalization, as opposed to a new category of ICD-10-CM codes that 
would be considered for the exclusions list. The new MS-DRGs will also 
mean that the hip fracture list will become irrelevant in most cases, 
as episodes with hip fracture will be identified by the MS-DRG rather 
than primary ICD-10-CM code associated with the MS-DRG. (Although the 
hip fracture list would be used to identify a hip fracture in the case 
of an outpatient THA, we expect that THA in the presence of a hip 
fracture will almost always be performed in the inpatient setting.) 
Given the relative stability of the ICD-10-CM code set used to 
determine hip fractures and exclusions, we proposed to discontinue our 
annual sub-regulatory process to update the hip fracture list and 
episode exclusions list. We sought comment on our proposal and whether 
there are any circumstances in which updates may still be needed.
    Comment: A commenter did not oppose CMS' proposal to freeze the hip 
fracture and exclusions list.
    Response: We appreciate the comment. We note that we did not 
receive any comments opposing our proposal to freeze the hip fracture 
and exclusions list.
    Final Decision: After consideration of the public comments 
received, we are finalizing our proposal to freeze the hip fracture 
list and episode exclusions list.

B. Target Price Calculation

1. Background
    Currently in the CJR model, participant hospitals are provided with 
prospective episode target prices for four MS-DRG/hip fracture 
combinations (MS-DRG 469 with hip fracture/MS-DRG 521, MS-DRG 469 
without hip fracture, MS-DRG 470 with hip fracture/MS-DRG 522, and MS-
DRG 470 without hip fracture), based on historical episode spending. 
Participant hospitals have the opportunity to achieve a reconciliation 
payment if their performance year spending is below the applicable 
target price, or they may owe a repayment if their spending is above 
the applicable target price. More specifically, we finalized in the 
November 2015 final rule (80 FR 73338) the method for establishing 
episode target prices based on 3 years of standardized historical 
episode spending. This historical spending is updated by trending 
forward the older 2 years of historical data to the most recent of the 
3 years being used to set target prices (80 FR 73342). We calculate and 
apply different national trend factors for each combination of anchor 
MS-DRG (469 vs. 470) and hip fracture status (with hip fracture vs. 
without hip fracture). While the CJR model began with a blend of 
regional (``region'' defined as one of the nine U.S. Census divisions 
\5\) and hospital-specific spending for PYs 1 through 3, episode target 
prices were based on 100 percent regional spending beginning in PY4. 
Under current regulations, high episode spending is capped at 2 
standard deviations above the mean regional episode payment, and target 
prices are trended forward at reconciliation to represent performance 
period dollars. To increase historical CJR model episode volume and set 
more stable target prices, CJR model episodes are pooled together and 
anchored by MS-DRGs 469 and 470 (80 FR 73352) factors calculated at the 
regional- and hospital-specific levels. Target prices are then 
prospectively updated to account for ongoing Medicare payment system 
updates (that is, Inpatient Rehabilitation Facility Prospective Payment 
System (IRF PPS), Physician Fee Schedule (PFS), IPPS, OPPS, and SNF 
PPS) to the historical episode data (80 FR 73342). Medicare payment 
systems do not update their rates at the same time during the year. For 
example, the IPPS, the IRF PPS, and the SNF PPS apply annual updates to 
their rates effective October 1, while the hospital OPPS and Medicare 
PFS apply annual updates effective January 1. To ensure we 
appropriately account for the different Medicare payment system updates 
that go into effect on January 1 and October 1, we finalized a policy 
to update historical episode payments for Medicare payment system 
updates and calculate target prices separately for episodes initiated 
between January 1 and September 30 versus October 1 and December 31 of 
each performance year. After target prices are updated for these system 
updates, local wage factors are used to convert standardized prices 
back to actual prices, and a 3 percent discount is applied to represent 
Medicare savings.
---------------------------------------------------------------------------

    \5\ There are four census regions--Northeast, Midwest, South, 
and West. Each of the four census regions is divided into two or 
more ``census divisions.'' Source: https://www.census.gov/geo/reference/gtc/gtc_census_divreg.html. Accessed on September 27, 
2019.
---------------------------------------------------------------------------

2. Overview of Changes to Target Price Calculation
    Since the CJR model was implemented in 2016, both TKA and THA have 
been removed from the IPO

[[Page 23509]]

list, as discussed in section II.A. of this final rule. In addition, 
there have been several other Medicare payment policy changes, such as 
changes to the SNF payment system to move from Resource Utilization 
Groups (RUGs) to the Patient Driven Payment Model (PDPM). Additionally, 
as noted in Table 2 in this final rule, national expenditures for LEJR 
procedures and associated post-acute care services have been decreasing 
since 2016. While average episode payments declined for both the CJR 
model and control group episodes during the first 2 performance years 
of the model, payments declined more for the CJR model episodes. 
Average episode payments decreased by $997 more for the CJR model 
episodes than for control group episodes from the baseline to the 
intervention period (p<0.01). This relative reduction equates to a 3.7 
percent decrease in average episode payments for the CJR model episodes 
from the baseline.\6\
---------------------------------------------------------------------------

    \6\ See pg. 3 of the CJR Second Annual Report available on: 
https://innovation.cms.gov/Files/reports/cjr-secondannrpt.pdf
---------------------------------------------------------------------------

    Trend data now shows that the decrease in national expenditures 
observed by the CJR model evaluation for the CJR participant hospitals 
and non-CJR participant hospitals for the first 2 years of the model 
actually began prior to the implementation of the CJR model and has 
continued consistently post 2016. This improved efficiency can be seen 
through shorter hospital stays and lower SNF usage. Table 1 shows the 
summarized Medicare claims data for LEJR per episode spending outside 
of the CJR model.
[GRAPHIC] [TIFF OMITTED] TR03MY21.001

    Excluding CJR participant hospitals, national per episode costs for 
hip and knee replacement procedures calculated using Medicare claims 
data dropped by about eight percent from 2014 to 2017, largely due to 
reductions in the utilization of post-acute services. In analyzing 
Medicare claims data from the CMS Integrated Data Repository (IDR) as 
of April 2019, we constructed CJR model episode costs for all IPPS 
providers and looked at average per episode spending by region for 
2016, 2017, and 2018. While per episode costs generally decreased for 
all regions between 2016 and 2018, most regions had a slight increase 
in episode spending between 2017 and 2018, as shown in Table 2.
[GRAPHIC] [TIFF OMITTED] TR03MY21.002

    Although the CJR model target price methodology currently includes 
a DRG/hip fracture specific national trend update factor and twice 
yearly updates for changes in the Medicare prospective payment systems 
and fee schedules,

[[Page 23510]]

those updates do not capture shifts in spending between the target 
price and the model performance year and consequently, the current 
target prices have not accounted for nationwide reductions in LEJR 
spending from shifting care settings and more efficient care delivery. 
Therefore, we proposed to change the target price update methodology to 
use region/MS-DRG/hip fracture specific retrospective trend adjustments 
to ensure that target prices better capture spending trends and 
changes. We note that in considering proposed changes to the target 
price structure for the CJR model, we did consider an option of setting 
prices at the national, rather than regional level. While we did not 
elect to model this proposal and instead proposed to continue the 
regional pricing approach, we sought comment on the appropriateness of 
moving to national pricing approach in future years of the CJR model 
with the goal of removing price variation due to differences in 
regional care delivery patterns.
    CJR model target prices are set based on 3 years of baseline data, 
with the 3-year baseline data updated every other year. When this 
policy was established we were concerned that we would not have enough 
claim volume in 1 or 2 years of data to set reasonably accurate 
hospital-specific prices, especially for smaller hospitals. Our 
proposed approach to target price calculation differs from the current 
approach as it involves setting target prices based on 1 year (the most 
recently available year) of baseline claims data. The baseline claims 
data used to establish target prices would be updated each year.
    We proposed this change because our initial concern of insufficient 
episode volume stemmed from the fact that we incorporated hospital-
specific pricing for the first 3 years of the CJR model. At this point 
in time, that concern has been mitigated as the baseline data used for 
target price calculations has moved from a blend of regional and 
historical baseline data (PYs 1 through 3) to 100 percent regional 
pricing (PYs 4 and 5). Additionally, since we proposed to include 
outpatient TKA/THA procedures as well as inpatient admissions for MS-
DRG 469 or 470 in the CJR model episode definition (which as of October 
1, 2020 has also included MS-DRG 521 and 522), we have determined that 
the most recently available 1 year of data will in fact be a more 
appropriate baseline period on which to set target prices as it 
contains both inpatient and outpatient LEJR claims.
    As described in section II.C.6 of this final rule, a trend factor 
adjustment applied during reconciliation would account for shifts in 
the trend of national per episode spending. To the extent that the 
trend, which is the percent difference between 2 years of data, 
decreases (as illustrated in Table 2 for 2016 relative to 2018), target 
prices would decrease. However, if the percent difference shows an 
increase (as illustrated in Table 2 for 2017 relative to 2018), target 
prices would increase. Using 1 year of data (rather than 3) removes the 
need for the national trend update factor we previously used to trend 
forward the older 2 years of historical data to the most recent of the 
3 being used to set target prices (80 FR 73342); we therefore proposed 
to remove the national trend update factor. We also proposed not to 
update the target prices twice a year for changes to Medicare 
Prospective Payment Systems and Fee Schedules, as we believe the new 
reconciliation trend factor adjustment we proposed would capture any 
payment changes in addition to any spending trend shifts.
    Acknowledging the proposed episode definition changes described in 
section II.A.2 of this final rule, for the purpose of calculating CJR 
model episode target prices for PY6 through 8 we proposed that Part A 
and B Medicare claims data for beneficiaries with CJR model episodes 
(that is, beneficiaries with a claim for an MS-DRG 470, 469, 522 or 521 
or a permitted outpatient TKA/THA procedure billed by a CJR participant 
hospital) would be grouped into one of the following types of CJR model 
episodes:
     MS-DRG 470 with hip fracture (now MS-DRG 522), which would 
include outpatient THA episodes with hip fracture.
     MS-DRG 470 without hip fracture (now MS-DRG 470), which 
would include outpatient TKA episodes and outpatient THA episodes 
without hip fracture.
     MS-DRG 469 with hip fracture (now MS-DRG 521).
     MS-DRG 469 without hip fracture (now MS-DRG 469).
    We note that, due to the addition of MS-DRGs 521 and 522 to the CJR 
episode definition, we will make the following adjustment to the 
baseline episodes used to calculate target prices for PY6 only, because 
that will be the only year when the baseline data (2019) will not 
include the new MS-DRGs, while the performance year data will include 
the new MS-DRGs. For PY6 only, since target prices will be based on the 
original MS-DRGs but apply to performance period episodes with the new 
MS-DRGs, we will adjust the IPPS payment in baseline episodes with hip 
fracture, multiplying the baseline IPPS payment by the ratio of the new 
MS-DRG weights for 521 and 522 in the performance period to the MS-DRG 
weights for 469 and 470 in the baseline period, which will result in 
target prices that more accurately reflect the methodology we proposed 
in the February 2020 proposed rule. Our methodology assumed that the 
IPPS portion of TKA and THA episodes would differ only by the presence 
or absence of MCC, regardless of hip fracture status. That is, although 
we calculated target prices separately for episodes with and without 
hip fracture due to higher post-acute care costs for episodes with a 
hip fracture, the IPPS payment for MS-DRG 469 with and without hip 
fracture was based on a single MS-DRG weight, as was the IPPS payment 
for MS-DRG 470 with and without hip fracture. The introduction of 
separate MS-DRGs based on hip fracture status means that IPPS payments 
for TKA and THA episodes, which would have reflected one of two 
different MS-DRG weights based on MCC in the baseline, would reflect 
one of four different MS-DRG weights based on both MCC and hip fracture 
status in the performance period. For instance, in FY 2019, the weight 
assigned to MS-DRG 470, which included both hip fracture and non-hip 
fracture episodes without MCC, was 1.9898 (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Downloads/FY2019-CMS-1694-FR-Table-5.zip). In FY 2021, the year that MS-DRGs 521 
and 522 became effective, the weight assigned to MS-DRG 470, which only 
included non-hip fracture episodes without MCC, was 1.8999, while the 
weight assigned to MS-DRG 522, which only included hip fracture 
episodes without MCC, was 2.1891 (https://www.cms.gov/files/zip/fy-2021-ipps-fr-table-5.zip). As we expect that FY 2022 weights for these 
MS-DRGs will similarly reflect greater resource utilization associated 
with MS-DRG 522 as compared to MS-DRG 470, using 2019 data without 
adjusting for the change in the MS-DRG weights could potentially cause 
us to overestimate the cost of appropriate care for MS-DRG 470 episodes 
and underestimate the cost of appropriate care for MS-DRG 522 episodes 
during the performance period. By overestimating or underestimating 
target prices in this way, we could inadvertently reduce savings for 
Medicare when the target price was overestimated and incentivize 
stinting of care when the target price was underestimated. Post-acute 
spending for

[[Page 23511]]

these episodes will be subject to the market trend factor. For PY7 
through 8 target prices, both the baseline and performance period will 
include MS-DRG 521 and 522, so the MS-DRG adjustment will no longer be 
necessary, and all costs for all episodes will be subject to the market 
trend factor.
    To then calculate target prices for PYs 6 through 8, baseline 
episodes would be stratified into the applicable nine geographic 
regions, where regional assignment for a given episode would be based 
on the region to which the MSA for the hospital maps under the CJR 
model. This would result in 36 separate episode groups, as there would 
be one group for each region, and MS-DRG. Within each of the 36 groups, 
we would then array the episode costs, and, consistent with our 
proposed new methodology for deriving the high episode spending cap 
amount, we would cap episode costs at the 99th percentile amount within 
each region/MS-DRG combination. We note that the proposed methodology 
of capping high episode spending at the 99th percentile would replace 
the current high episode spending cap methodology, which sets the cap 
at 2 standard deviations above the mean regional episode payment. We 
would then calculate the mean episode cost within each group of capped 
episodes, resulting in 36 average regional target prices. Starting in 
PY6, at the beginning of each performance year, these average regional 
target prices would be posted on the CJR model website.
    Finally, we note that we proposed to remove the use of an anchor 
factor and regional- and hospital-specific anchor weights from the 
target price calculation that we established in the original November 
2015 final rule (80 FR 73273). We originally included this step in the 
target price calculation to set more stable target prices using a 
greater volume of CJR model episode data, which was more of a concern 
when the model began due to the hospital-specific pricing component in 
PY1 to PY3. During PY1 through PY3, CJR model episodes anchored by MS-
DRGs 469 and 470 were pooled together during target price calculations 
to have a greater historical CJR model episode volume and set more 
stable target prices, noting that the hospital-specific pooled 
calculations are later ``unpooled.'' Specifically, we set the MS-DRG 
470 anchored episode target price equal to the target price resulting 
from the pooled calculations. We then multiplied that MS-DRG 470 target 
price by the anchor factor to produce the MS-DRG 469 anchored target 
prices. The calculation of the hospital weights and the hospital-
specific pooled historical average episode payments is comparable to 
how case mix indices are used to generate case mix-adjusted Medicare 
payments. The hospital weight essentially counts each MS-DRG 469 
triggered episode as more than one episode (assuming MS-DRG 469 
anchored episodes have higher average payments than MS-DRG 470 anchored 
episodes) so that the pooled historical average episode payment, and 
subsequently the target price, is not skewed by the hospital's relative 
breakdown of MS-DRG 469 versus MS-DRG 470 anchored historical episodes. 
However, since PY4 and PY5 use only regional episode spending data to 
calculate target prices, and since we proposed for PYs 6 through 8 to 
continue to use only regional episode spending data to calculate target 
prices and to utilize only the most recently available year of episode 
data for target price calculations, we do not believe volume issues 
will be a concern and thus we do not believe it is necessary to 
continue to perform these steps. Therefore, we proposed to no longer 
use the regional and hospital anchor weighting steps from the original 
CJR model target price calculation methodology.
    At the time the proposed rule was published, CMS did not have the 
necessary data (for example, outpatient data) to calculate and provide 
sample target prices reflecting the proposed changes to the target 
price methodology. However, we are including a sample of these target 
prices for PY6 in Table 2a in this final rule. While these target 
prices reflect the target price methodology changes described in this 
section, they will not be the exact target prices used for PY6. As 
stated in section II.B.2 of this final rule, we will post official PY6 
target prices on the CMS website in June 2021. The target prices 
described in Table 2a of this final rule are meant to serve as an 
example; we will update the 2019 baseline data again before calculating 
the official PY6 target prices to ensure completeness of the 2019 data.
[GRAPHIC] [TIFF OMITTED] TR03MY21.003

    The preliminary MS-DRG 470 target prices described in this table 
were calculated using the blended inpatient/outpatient target prices, 
as described in section II.A.2 of this final rule. We further note that 
the IPPS payment for

[[Page 23512]]

episodes with hip fracture in the baseline initiated by MS-DRGs 469 and 
470 with hip fracture in 2019 will be adjusted as described in section 
II.B.4 of this rule so that they will be comparable to episodes 
initiated by the new MS-DRGs 521 and 522 during the performance year.
    The following is a summary of the comments received and our 
responses.
    Comment: Commenters in general were supportive of the proposed 
changes to the target price methodology but noted concern and 
considerations about certain changes. A commenter stated that for 
target price calculations, CMS should consider whether the size of the 
regions need to be modified based on previous years' findings or if 
there is significant market variability within a single region. A 
commenter urged CMS to evaluate the impact of the transition to 
regional only target pricing on safety-net hospitals that do not 
compete on a regional basis and that might otherwise value the 
predictability of target prices based on hospital-specific data.
    Response: The CJR model shifted to regional only pricing starting 
in PY4, and final reconciliation results from PY4 are not complete at 
this time. However, we continue to believe that this transition to 
using regional only data for target price calculations will provide 
valuable information regarding potential pricing strategies for 
successful episode payment models to reduce variation in LEJR episode 
payments and reward hospitals for reducing payments below their 
regional peers. We have no evidence to date suggesting significant 
variation within a single region that would lead us to consider 
alternative geographic regions. While safety-net hospitals may value 
predictability of target prices based on hospital-specific data, we are 
committed to continuing to test the regional only approach for CJR 
participant hospitals, including safety-net hospitals, which could 
strengthen the generalizability of the evaluation results. We also 
consider that the proposed risk adjustment methodology, which we are 
adopting with modification as described in section II.C.4 of this rule, 
will ensure that participant hospitals treating a higher proportion of 
complex patients are adequately provided upward risk adjustments to 
their target prices as a result of those costlier patients. 
Additionally, since all participant hospitals participating in PY6 
through PY8 will have already participated in at least one of the 
performance years PY1 through PY5 of the CJR model, we anticipate these 
hospitals will be familiar with the CJR model approach to target price 
calculations based on regional only data and a regression back to 
hospital-specific data could be confusing.
    Comment: MedPAC suggested CMS move to national target prices, which 
should be adjusted to reflect local or regional input costs, stating 
this would incentivize providers in high-cost areas to reduce post-
surgical service use and would reward providers in low-cost areas with 
larger shared savings payments than providers in high-cost areas.
    Response: We understand that moving to target prices calculated 
from national data may enhance the incentive for some areas to reduce 
episode costs compared to higher cost areas, but we proposed to 
maintain regional only pricing to ensure stability for existing CJR 
model participants that will only have experience with target prices 
calculated from regional-only data for 2 performance years in the CJR 
model before PY6 begins. Due to the addition of outpatient procedures 
to the CJR model episode definition, we also expect that regional data 
is more appropriate to use for target pricing in PYs 6 through 8 given 
the potential variation in outpatient utilization nationally, similar 
to the substantial regional variation in utilization for episodes 
involving LEJR procedures, as referenced in the November 2015 final 
rule.\7\ CMS appreciates MedPAC's suggestions to generate additional 
savings for the Medicare program by increasing the discount factor or 
increasing the stop-loss limit. Many of the changes CMS proposed to the 
CJR model payment methodology for PYs 6 through 8 are intended to be 
improvements to the original methodology that will increase the 
probability for model savings. While CMS could design a payment 
methodology that attributed a much larger portion of savings to the 
Medicare program, we must also balance the administrative burden and 
investments needed by participating hospitals to be successful under 
the model, and thus proposed a methodology--intended to ensure that CJR 
participant hospitals are still capable of achieving a certain level of 
savings for themselves in the model.
---------------------------------------------------------------------------

    \7\ Hussey PS, Huckfeldt P, Hirshman S, Mehrotra A. Hospital and 
regional variation in Medicare payment for inpatient episodes of 
care [published online April 13, 2015]. JAMA Intern Med. 
doi:10.1001/jamainternmed.2015.0674.
---------------------------------------------------------------------------

    Comment: A few commenters requested that CMS ensure that any 
changes to the CJR model payment methodology in general account for the 
range of patient complexity and underlying operating costs for sites 
treating more complex patients in order to avoid unnecessarily 
penalizing high quality providers caring for complex patients.
    Response: We understand the commenters' requests for a payment 
methodology that attempts to accurately account for variation in 
episode costs related to patient complexity. The CJR model initially 
provided risk adjustment for MS-DRG 470 and MS-DRG 469 patients with 
the presence of a hip fracture during PYs 1 through 5 in recognition 
that these patients had higher episode costs compared to non-fracture 
patients. We also chose that risk adjustment method to protect small 
and rural participants that may disproportionately have more emergent 
surgeries, such as hip fractures, in those low-volume settings. The 
proposed additional risk adjustment variables, as described in section 
II.C.4. of this final rule, were proposed with these same goals in mind 
and are meant to further increase the accuracy of target price risk 
adjustments for PYs 6 through 8. We also recognize that without risk 
adjustment the addition of outpatient TKA/THA to the CJR model episode 
definition, as described in section II.A.2 of this final rule, could 
create pressure for clinicians to recommend the lower cost outpatient 
setting to minimize total episode costs. The objective of the risk 
adjustment methodology for PYs 6 through 8 is to incentivize clinicians 
to continue performing LEJR procedures in the most appropriate clinical 
setting based on their assessment of each patients' complexity, and we 
appreciate that this aligns with commenters' requests for a methodology 
that accounts for the range of patient complexity and costs associated 
with treating more complex patients.
    Comment: A commenter noted that in comparison to the concept of 
bundles in the commercial insurance market, the payment methodology in 
the CJR model does not include consideration of such costs and market 
indicators like innovation, inflation, and an increasingly expensive 
labor market given the lowering of unemployment. The commenter asserted 
that under this payment methodology, there will be a point where there 
will only be losses in offering THA/TKA procedures to Medicare patients 
leading to loss of access to these procedures.
    Response: CMS notes the CJR model was specifically designed for 
implementation in the Medicare program, where hospitals and 
beneficiaries are faced with different considerations and choices in 
the commercial insurance market, such as payment rates and beneficiary 
benefits. The retrospective market trend factor

[[Page 23513]]

and risk adjustment components of the proposed payment methodology are 
intended to produce accurate target prices that reflect the average 
regional costs. While the market trend factor may have the effect of 
decreasing target prices as a result of lower performance period 
average costs compared to baseline costs, as we note in section II.C.6. 
of this final rule, the market trend factor could also have the effect 
of increasing target prices to reflect higher performance period 
average costs, including market conditions such as inflation and labor 
costs. We do not believe the target price methodology will have the 
effect of decreasing access to THA and TKA procedures given the 
proposed market trend factor and 1 calendar year of baseline data that 
should appropriately align performance period spending with baseline 
spending.
    Comment: A few commenters stated that CMS provided insufficient 
data and did not fully describe the proposed target price methods and 
results of the simulated comparisons to allow independent analyses by 
stakeholders. In particular, a commenter requested that CMS make 
available all of the relevant data, along with a complete description 
of the analytic methodologies used in constructing the four target 
pricing episode categories, as well as sample site-neutral target 
prices for the nine census regions, and that the comment period be 
extended 60 days from the day on which the data and methodology details 
are provided.
    Response: We recognize the commenters' interest in obtaining the 
data CMS used to develop the changes to the CJR model target price 
methodology and creating simulated comparisons of that methodology. In 
the February 2020 proposed rule, we provided information and data 
regarding our target price methodology decision making, such as our 
decision to adopt a blended target price for outpatient procedures 
given the clinical rationale to combine those episode types (that is, 
outpatient and inpatient episodes). In particular, we recognize the 
risk adjustment methodology, described in section II.C.4 of this final 
rule, represents a significant change in how target prices will be 
calculated and how episodes will be reconciled in PYs 6 through 8. We 
described our rationale for choosing the risk adjustment variables we 
are adopting in this final rule, including the analytic methodologies 
to calculate the risk adjustment coefficients and the exact dates of 
claims data used to perform the analysis. We also included a discussion 
in that section about our consideration for alternative analytic 
methodologies and our decision to employ logarithmic transformation in 
the exponential model used to calculate risk adjustment coefficients. 
Additionally, we are adding detail in that section of this final rule 
regarding the decision to calculate risk adjustment coefficients 
nationally rather than regionally. Our approach is similar, both in 
terms of rationale and level of detail of the analytic methods and 
considerations, to what we provided in November 2015 rule (80 FR 
73273), and for this reason, we believe that the information we 
provided in the proposed rule was sufficient.
    However, since some components of the target price methodology for 
PYs 6 to 8 are identical to the methodology used for PYs 1 to 5 and are 
described in depth in the final rule establishing the CJR model (80 FR 
73273), such as the length of an episode or use of regional only data 
(recognizing use of regional data began in PY4), so we did not repeat 
those components in detail in the proposed rule. While CMS recognizes 
there is a degree of uncertainty regarding the effect of the 
retrospective market trend factor or other components of the target 
price methodology, we believe the data and information we provided in 
the proposed rule and this final rule are sufficient to inform 
stakeholders of the changes we are adopting in this final rule. Similar 
to the original CJR model, we intend to conduct webinars detailing the 
payment methodology, in addition to making available other learning on 
the CMS website. As stated in section II.B.2. of this final rule, we 
will also post applicable (site-neutral) regional target prices for 
each of the four episode types, as well as the risk adjustment 
coefficients on the CMS website prior to the start of each performance 
year. In this final rule, we include sample site-neutral PY6 target 
prices, which can be found in Table 2a of section II.B.2 of this final 
rule. We also posted updated PY6 risk adjustment coefficients, 
including the addition of the dual-eligible status risk variable, in 
Table 3a and Table 4a in section II.C.4 of this final rule. Since the 
2019 claims data used to calculate these sample target prices and risk 
adjustment coefficients were unavailable at the time the proposed rule 
was published, we were unable to include that information in the 
proposed rule. We anticipate posting final PY6 site-neutral target 
prices and final PY6 risk adjustment coefficients on the CMS website in 
June 2021.
    Comment: A commenter requested that CMS provide target price 
estimates calculated from Medicare claims data for bundles that include 
the status quo (current model), the proposed episode targets, and the 
targets if inpatient and outpatient episodes were priced separately.
    Response: For a sample of the site-neutral PY6 target prices 
calculated using the proposed changes to the target prices methodology, 
we direct the reader to Table 2a in this final rule. As stated in 
section II.B.2 and section II.C.4 of this final rule, we will also post 
applicable (site-neutral) regional target prices for each of the four 
episode types as well as the risk adjustment coefficients on the CMS 
website prior to the start of each performance year. We anticipate 
posting PY6 site-neutral target prices and PY6 risk adjustment 
coefficients on the CMS website in June 2021. For an analysis of the 
proposed payment methodology, including the effect of excluding 
outpatient episodes from the episode definition, we direct readers to 
Table 6a and the related discussion in section IV.C. of this final 
rule.
    Comment: A commenter requested that CMS provide clear and specific 
guidance on the impacts of payment adjustment changes and overlap 
across initiatives for organizations that participate in multiple 
value-based care models or programs, like the CJR model, BPCI Advanced, 
the Medicare Shared Savings Program (Shared Savings Program), and 
others.
    Response: The CJR model overlap policies that applied during PYs 1 
through 4 and each subset of PY5 will be applied when possible for PYs 
6 through 8. However, we have determined that certain overlap policies 
that we proposed to apply to PYs 6 through 8 will not be feasible due 
to having only one reconciliation at six months after the end of the 
performance year, and we will no longer have a second reconciliation at 
14 months after the end of the performance year. Therefore, although we 
are finalizing the changes to Sec.  510.305(j)(1) that we adopted in 
the November 2020 IFC, which apply the provisions of that section to 
the subsets of PY5, we are not finalizing the changes to Sec.  
510.305(j)(1) that we proposed in the February 2020 proposed rule, 
which would have applied to PYs 6 through 8 our current policy of 
adjusting for shared savings payments when a CJR participant hospital 
is also a participant or provider/supplier in certain Accountable Care 
Organization (ACO) models or programs to which a CJR beneficiary is 
aligned. Those adjustments will no longer be feasible for PYs 6 through 
8 because, as a result of the shorter time period between the end of 
the performance period and the

[[Page 23514]]

reconciliation calculation, we will not have access to the 
reconciliation data from ACO initiatives that would be necessary to 
allow us to perform the those adjustments.
    Although not all of our proposed policies related to overlap can be 
maintained in PYs 6 through 8, we are maintaining the policy described 
at Sec.  510.200(d)(4)(iii), which excludes certain per beneficiary per 
month (PBPM) payments under models tested under section 1115A of the 
Act. We are finalizing our proposal at Sec.  510.200(d)(4) to extend 
this exclusion to episodes triggered by an anchor procedure, in 
addition to those triggered by an anchor hospitalization for PYs 6 
through 8. In this final rule, we are also revising the list of ACO 
models or programs for which a prospectively aligned beneficiary is 
excluded from initiating a CJR episode in order to continue applying 
the policy specified at Sec.  510.205(a)(6) in PYs 6 through 8. 
Specifically, we are replacing the reference to a Shared Savings 
Program ACO in Track 3 in Sec.  510.205(a)(6)(iii) with a reference to 
a Shared Savings Program ACO in the ENHANCED track. Although we did not 
propose this change, we believe it is appropriate to include it in this 
final rule as a conforming change because the ENHANCED track of the 
Shared Savings Program is the successor of Track 3, as noted in Sec.  
425.600(a)(3), and our intention is to maintain this overlap exclusion 
policy.
    Additionally, we are clarifying in this final rule that the overlap 
policies described at Sec.  510.305(i)(1), which account for episode 
cancelations due to overlap between the CJR model and other CMS models 
and programs or for other reasons as specified in Sec.  510.210(b), 
will occur at the single reconciliation during PYs 6 through 8. As 
described in the November 2015 final rule establishing the CJR model, 
we reserved these policies for the subsequent reconciliation (which 
takes place 14 months after the end of the performance year) to provide 
additional time beyond the initial reconciliation (which takes place 2 
months after the end of the performance year) for claims run-out after 
an episode ended and to gather data about beneficiary alignment with 
other CMS models and programs. While we do not expect to have access to 
ACO reconciliation data that would allow us to perform the overlap 
adjustment described at Sec.  510.305(j)(1) during PYs 6 through 8, as 
described previously, we do expect that ACO beneficiary alignment data 
will be available at the single reconciliation for PYs 6 through 8 
(which will take place 6 months after the end of the PY) in order to 
identify episodes that are canceled in accordance with Sec.  
510.210(b). In this final rule, we are adding regulation text at Sec.  
510.305(m)(1)(v) to describe how this policy will be applied during PYs 
6 through 8.
    Lastly, regarding BPCI Advanced, we note the BPCI Advanced 
Participation Agreement (available at: https://innovation.cms.gov/files/x/bpciadvanced-my3-am-restated-participation-agmt.pdf) states 
``In the event that a Participant or, if applicable, a Downstream 
Episode Initiator is also participating in an Innovation Center model 
implemented via regulation (for example, the Comprehensive Care for 
Joint Replacement (CJR) model), the Participant will not be held 
accountable for any Clinical Episodes included in that model for 
purposes of BPCI Advanced. Furthermore, in the event the Participant is 
located in one or more Metropolitan Statistical Areas included in an 
Innovation Center model implemented via regulation (for example, the 
CJR Model), CMS will exclude from the BPCI Advanced Reconciliation 
calculation all clinical episodes included in that model.''
    Final Decision: After consideration of public comments we received, 
we are finalizing overlaps policies with some modifications. We are not 
finalizing the overlaps policy described in our proposed amendments to 
Sec.  510.305(j)(1) because this proposal sought to continue into PYs 6 
through 8 a particular overlaps adjustment calculation that is 
conducted during the subsequent reconciliation for which we will not 
have the required data available at the time of the single 
reconciliation for PYs 6 through 8. We are finalizing our proposal at 
Sec.  510.200(d)(4) that applies the exclusion specified in Sec.  
510.200(d)(4)(iii) to episodes triggered by an anchor procedure, and we 
are making a conforming change to the regulation text at Sec.  
510.205(a)(6)(iii) to continue applying that overlap exclusion policy 
to the successor to Track 3 of the Shared Savings Program, which is the 
ENHANCED track. Finally, we are adding regulation text at Sec.  
510.305(m)(1)(v) to clarify how the overlaps policies described in 
Sec.  510.305(i)(1) will be applied during the single reconciliation in 
PYs 6 through 8.
3. Change to One Year of Baseline Data
    The CJR model currently uses 3 years of baseline data to calculate 
initial target prices, with the 3-year baseline data updated every 
other year. As we stated when we finalized this policy, we chose 3 
years because we wanted to ensure that we would have sufficient 
historical episode volume to reliably calculate target prices (80 FR 
73340). We stated that our purpose for updating the baseline every 
other year was to achieve a balance between using the most recently 
available data to reflect changes in utilization and minimizing 
uncertainty in pricing for participant hospitals.
    When we chose to use 3 years of historical data we were 
specifically concerned that some hospitals might not have a sufficient 
volume of episodes to create a reliable target price, particularly for 
the less frequent MS-DRG 469 episodes, because target prices in PYs 1 
through 3 incorporated hospital-specific data into target prices. 
Hospital-specific data was incorporated into target prices to more 
heavily weight a hospital's historical episode data in the first 2 
years of the model (two-thirds hospital-specific, one-third regional) 
and provide a reasonable incentive for both historically efficient and 
less efficient hospitals to deliver high quality and efficient care in 
the early stages of model implementation. Therefore, it was important 
in the first 3 performance years to have 3 years of historical data to 
ensure that individual hospitals had an adequate volume of historical 
episode data upon which to base target prices. However, target prices 
beginning with PY4 are based entirely on aggregated regional episode 
spending data, rather than a blend of both regional- and hospital-
specific data. Our concerns relating to an adequate volume of 
historical episode data are therefore mitigated. We also note that we 
proposed additional tools meant to ensure accuracy of target pricing, 
specifically, the trend factor discussed in section II.C.6. of this 
final rule and risk adjustment discussed in section II.C.4 of this 
final rule, which further mitigates our concerns regarding target 
pricing uncertainty. Therefore, we believe that for the proposed CJR 
model extension, 1 year of data will be sufficient to calculate target 
prices for all participant hospitals.
    Furthermore, given the removal of TKA from the IPO list, along with 
the national shift in LEJR spending, we have determined that the most 
recently available 1 year of data will in fact be a more appropriate 
baseline period on which to set target prices. Specifically, the 
removal of TKA from the IPO list, which has led us to propose to allow 
outpatient TKA procedures to trigger CJR model episodes (see section 
II.A of this final rule), only became effective in CY 2018. As a 
result, CY 2018 is the earliest year for which we will have

[[Page 23515]]

available data that includes both inpatient and outpatient TKAs, which 
will be needed to calculate a target price for a blended inpatient/
outpatient TKA episode within the category of MS-DRG 470.
    Therefore, for PYs 6 through 8, we proposed to use the most 
recently available 1 year of data prior to the start of the performance 
year to calculate target prices rather than the 3 years of data 
currently used. Under the current methodology, target prices for PYs 1 
and 2 were calculated with baseline data from 2012 to 2014, PYs 3 and 4 
were calculated with baseline data from 2014 to 2016, and PY5 is 
calculated with baseline data from 2016 to 2018. We proposed to base 
PY6 target prices on episode baseline data from 2019, PY7 target prices 
on episode baseline data from 2020, and PY8 target prices on episode 
baseline data from 2021. We proposed that by using only 2019 data for 
PY6 target prices, we would be able to capture spending patterns 
associated with the movement of TKA into the outpatient setting, as 
well as other practice trends during that year. Therefore, we stated 
our belief that using only the most recently available 1 calendar year 
of baseline data and updating that 1 year of baseline data annually 
will provide the best available picture of spending patterns we would 
expect to see during the performance period, which will allow us to 
calculate more accurate target prices. We sought comment on this 
proposal.
    The following is a summary of the comments received and our 
responses.
    Comment: Some commenters were in support of the proposed change to 
use 1 year of baseline data, with a few commenters stating that 1 
calendar year of baseline data is sufficient in supporting the 100 
percent regional pricing methodology as the volume of episodes is large 
enough to provide stability with pricing from a single year's worth of 
data. A commenter noted that 1 year of baseline data will more 
effectively capture Medicare payment policy changes over the last year, 
ensuring that the target price methodology is not an unintentional 
disincentive for the system of care due to not capturing appropriate 
costs. A commenter supported the use of 1 year of baseline data, but 
without the addition of outpatient TKA and THA procedures.
    Response: CMS agrees with commenters that regional episode volume 
enables CJR model target prices to be calculated based on 1 calendar 
year of baseline data and that using the most recently available 
calendar year of data will more effectively capture Medicare payment 
policy changes compared to the PY1 through PY5 method that utilized 3 
years of baseline data. As noted in section II.A.2 of this final rule, 
we are adopting the inclusion of outpatient TKA and THA procedures in 
the CJR model episode definition for the 3-year extension to test the 
model in a broader population of beneficiaries than just those in the 
inpatient setting. Additionally, as noted in that same section of this 
final rule, given stakeholders' interest in opportunities to treat LEJR 
patients in the outpatient setting as part of a bundled payment model, 
we continue to believe this is important to the model test.
    Comment: Many commenters expressed concern that due to the COVID-19 
PHE, baseline data from 2020 and 2021 will be inappropriate to utilize 
for PY7 and PY8 target price calculations without adjustment to the 
proposed payment methodology. In particular, a few commenters expressed 
concern with using only 1 year of data and noted that if some areas in 
a region experience a surge in COVID-19 cases while other areas do not, 
the regional pricing model CMS is proposing would be a less valid way 
to adjust target pricing. A commenter noted that CMS should use 2019 as 
the baseline year for PY6 hold it constant for PYs 7 and 8, updated 
annually based on a trend factor that CMS would develop that holds 
providers harmless for the 2020 performance year due to the increased 
expenditures associated with COVID-19. A commenter noted that CMS 
should work with stakeholders as it develops a method for using 2020 as 
a base year for target price calculation in the future. Another 
commenter noted that moving to a 1 year baseline period would allow for 
a better comparison between baseline periods in which no THA procedures 
were performed on an outpatient basis to performance periods in which 
THA was removed from the IPO list; however, this commenter also noted 
that CMS should postpone implementing a 1 year baseline period given 
the COVID-19 pandemic.
    Response: CMS recognizes the concern expressed by commenters of 
using 2020 and 2021 baseline data for calculating target prices for PYs 
7 and 8 and the potential effect of the COVID-19 PHE on that data. 
However, we continue to believe that using the most recently available 
1 calendar year of baseline data (with the modification discussed later 
in this section) will more accurately capture recent trends in the LEJR 
market than the previous use of 3 years of data, specifically regarding 
the migration to outpatient procedures than using 3 years of data, 
given the pace of changes in practice trends. If the migration to the 
outpatient setting for these procedures is accelerated during PY6 as a 
result of the COVID-19 PHE and other changes to the LEJR market, we 
believe the use of 1 year of baseline data is important to more timely 
reflect changes in episode spending patterns and the case mix of 
patients receiving a procedure in the outpatient or inpatient setting. 
Specifically, if we relied on the original CJR model methodology of 
using 3 years of baseline data to calculate target prices for PY6, we 
would use data from 2016-2018. Using the averages over 3 years of 
claims data to calculate target prices instead of using 1 year (that 
is, calendar year 2019 claims data for PY6) could create inaccurate 
target prices for outpatient episodes since the data would only contain 
1 year of TKA outpatient data (that is, 2018), and it would not 
sufficiently capture the effect of the quickly evolving trends in the 
LEJR space noted in section II.A.2 of this final rule. The goal of the 
changes and extension of the CJR model adopted in this final rule are 
meant to inform the design of a future LEJR model that could be 
certified and expanded nationally, and we continue to believe using 1 
calendar year of baseline data is critical and appropriate for that 
future model.
    We also understand and agree with commenters that baseline data 
from 2020 will likely not be as reflective of true market conditions as 
if the COVID-19 PHE had not occurred, and agree with commenters that 
modifications must be made to avoid using baseline data from 2020. As 
described in section II.D.1. of this final rule, we are finalizing the 
start and end dates for PYs 6 through 8 as follows: PY6 will be October 
1, 2021 to December 31, 2022; PY7 will be January 1, 2023 to December 
31, 2023; and PY8 will be January 1, 2024 to December 31, 2024. Given 
the new start and ends dates of PYs 6 through 8, our model timeline is 
essentially shifting forward 12 months, such that PY7 will now begin 
with episodes ending on or after January 1, 2023. Given the timeline 
shift, we will now have access to 2021 calendar year claims data prior 
to the start of PY7. Using 2021 claims data to calculate target prices 
for the new PY7 timeline aligns with our intention to use the most 
recently available calendar year of baseline data, described in section 
II.B.3 of this final rule, and allows for the omission of 2020 calendar 
year claims data. Therefore, to accommodate commenters' suggestions of 
avoiding the utilization of 2020 claims data for target price 
calculation and to incorporate the

[[Page 23516]]

revised time frames for PYs 6 through 8, we are adopting the proposed 
methodology for PY6 but modifying the proposed methodology in Sec.  
510.300(b)(1)(v) so the date range of claims data used to calculate 
target prices for PY7 is January 1, 2021 to December 31, 2021. We are 
also modifying Sec.  510.300(b)(1)(vi), which specifies the date range 
of claims data used to calculate target prices for PY8 to be January 1, 
2022 to December 31, 2022 to accommodate the shift in PY7. We agree 
with commenters that 2020 data could be especially difficult to use for 
PY7 target price calculations. While 2021 data could also have similar 
distortions, we anticipate the corrective mechanisms of PYs 6 through 8 
payment methodology, in particular the market trend factors, will 
reduce this distortion. For example, the market trend factors will 
reduce the potential variation caused by the COVID-19 PHE in average 
episode costs calculated from calendar year 2021 data compared to PY7 
average episode costs. Since the market trend factors are calculated at 
the regional- and episode type-level, we anticipate they will 
accurately account for the potentially distorting effect of the COVID-
19 PHE. As 2020 claims data are finalized, and 2021 data become 
available, we will monitor the potentially distorting effects of the 
COVID-19 PHE on that data and determine if any adjustment is needed 
regarding use of the 2021 data for PY7 target prices calculations.
    Similarly, we are also finalizing corresponding changes to the 
timing of the data used to calculate the risk adjustment factors, 
described further in section II.C.4 of this final rule.
    Comment: Many commenters stated that 1 calendar year of baseline 
data would result in target prices that would be too variable, 
unpredictable, or susceptible to unexpected disruptions in the market 
compared to the 3 years of baseline data used previously. In 
particular, some of these commenters noted that more than 1 year of 
baseline data is necessary given the shift of TKA procedures to the 
outpatient setting in 2019, and because 2020 will be the first year of 
related Recovery Audit Contractor (RAC) audits and the first year THA 
procedures are payable in the outpatient setting. A commenter also 
noted that using 3 years of baseline data at the regional level creates 
additional stability in pricing due to the number of procedures 
included in the regional average compared to using a single year.
    Response: CMS continues to believe the most recently available 1 
calendar year of baseline data is sufficient and in fact preferred 
given the shift of TKA and THA procedures to the outpatient setting and 
other changes in the LEJR market environment, as described in section 
II.A.2 of this final rule. As noted previously, the timeline shift for 
PY7 in this final rule enables CMS to utilize 2021 calendar year claims 
data for PY7 target price calculations, which we anticipate will more 
accurately capture recent trends, such as the shift of TKA procedures 
to the outpatient setting, than 2020 calendar year claims data. 
Regarding the potential for using data from the first year of RAC 
audits of TKA procedures, we note that these reviews began in calendar 
year 2020 and, as described in section II.B.3 of this final rule, we 
will calculate PY6 target prices using calendar year 2019 data and PY7 
target prices using calendar year 2021 data, which will omit the first 
year of related RAC audits (that is, calendar year 2020) for which the 
commenter expressed concern of use for PY7 target price calculations. 
We anticipate that using only the most recent year of regional data, as 
well as incorporating the market trend factor discussed in section 
II.C.6 of this final rule, target prices will be more reflective of 
current spending patterns than using 3 years of data. We note that 
although the previous CJR model method of calculating target prices 
utilized 3 years of baseline data, the data was trended forward by a 
national growth factor and would still be susceptible, albeit to a 
lesser degree than simply 1 year of baseline data, to unexpected 
disruptions in the market. We recognized this potential susceptibility 
and proposed the market trend factor to mitigate its potential effects. 
While the retrospective nature of the market trend factor will change 
initial target prices at the subsequent reconciliation for each 
performance year, we note the risk adjustment coefficients posted on 
the CMS website prior to the start of each performance year will be the 
same coefficients applied at reconciliation each year. This is meant to 
increase the financial predictability for participants by holding 
constant the coefficients that are posted on the CMS website and used 
for reconciliation each performance year. Lastly, since target prices 
in PYs 6 through 8 will not be calculated with hospital specific data, 
we continue to believe there is little risk that a policy of using the 
most recent calendar year of data would result in insufficient volume 
of data related to certain episode types. We understand this risk from 
insufficient volume is greater as a result of the effect of the COVID-
19 PHE on the 2020 data and are finalizing, as described in section 
II.B.3. and section II.C.4. of this final rule, the policy that 2020 
claims data will not be used for target price or risk adjustment 
coefficient calculations, respectively. As noted previously, we also 
believe that using the most recent calendar year of baseline data for 
PY6 (that is, 2019 baseline data) will generate more accurate prices 
for the inclusion of outpatient procedures than the previous 
methodology that would have used baseline data from 2016 to 2018.
    Comment: Commenters noted that the CJR model's previous use of 3 
years of baseline data ensured that participant hospitals, in 
particular high performing hospitals, would not be penalized for their 
own improvements in cost.
    Response: We understand the concern that if the CJR model target 
prices were calculated with 1 year of hospital-specific baseline data 
alone it could be interpreted that a hospital's own improvements would 
inhibit their ability to achieve savings in later years of the model. 
However, the policy we are adopting in this final rule to use 1 year of 
regional only baseline data for target prices proposed for PYs 6 
through 8 will consider a participant hospital's performance relative 
to its regional peers (instead of the hospital's own historical 
performance) and will incentivize participants who are already 
delivering high quality and efficient care while still incentivizing 
historically less efficient providers to improve compared to their 
regional peers. Additionally, as we note in section II.C.4. of this 
final rule, the application of coefficients from the risk adjustment 
methodology is intended to also have the effect of rewarding hospitals 
that are able to provide care to certain beneficiaries (that is, those 
that trigger the application of the risk adjustment coefficients, such 
as patients with a CJR HCC count of three) at a lower cost compared to 
their peers.
    Comment: Another commenter stated concern that 2018-2020 national 
unadjusted CMS payment rates for TKA show a significant increase in the 
outpatient procedure payment and that this increase was overlooked by 
CMS.
    Response: We appreciate the suggestion by the commenter to consider 
the recent increase in payment rates for TKA procedures. As described 
in section II.B.3. of this final rule regarding the use of 1 year of 
baseline data, and in section II.C.6. of this final rule regarding the 
market trend factor, we anticipate both of those factors will ensure 
that annual variations in average episode costs are accurately adjusted 
in the updated CJR model payment methodology.

[[Page 23517]]

    Comment: A commenter recommended that CMS use 2019 data for 
baseline purposes to avoid continuous annual rebasing, other than to 
account for site of service shifts.
    Response: We proposed shifting the baseline data forward for each 
PY to ensure the target price methodology would effectively capture 
trends in the LEJR market. These trends include changes in payment 
systems and utilization of certain services, which would not be 
accounted for if we used the same year of baseline data for all 3 years 
of the extension and only included an adjustment for site of service 
shifts. In particular, 2019 baseline data will not reflect the 
migration to the outpatient setting for THA procedures that has 
occurred in 2020. We do believe that 2019 data will be an adequate 
baseline for calculating PY6 target prices in spite of the lack of 
outpatient THA data, given the similarity of average episode costs 
between outpatient TKA and outpatient THA episodes. We believe that it 
is preferable for PYs 7 and 8 target prices to be based on data that 
includes outpatient THA episodes, and we plan to use 2021 and 2022 
data, since that data will be newly available. As noted previously, we 
continue to believe using the most recent year of baseline data, as 
opposed to an adjustment we would develop each year, will more 
accurately capture spending trends related to site of service shifts or 
other market changes and is more transparent.
    Comment: A few commenters recommended CMS exclude beneficiaries 
from the baseline that were part of other APMs, such as the CJR model, 
BPCI Advanced, and Medicare ACOs.
    Response: The proliferation of APMs nationally represents a 
positive evolution in CMS' efforts to support better and more efficient 
care for beneficiaries. However, it also creates difficulties in 
discerning the effects of one APM vs. another. While the CJR model has 
certain overlap and beneficiary exclusion policies to ensure 
appropriate episode attribution during a performance year and at 
reconciliation, as noted in Sec.  510.305(i) for PYs 1 through 5 and in 
section II.B.2 of this final rule for PYs 6 through 8, we do not 
exclude these beneficiaries from baseline spending because, given the 
increasing reach and effect of APMs, it would be less reflective of 
actual average costs if the costs from those beneficiaries were 
excluded from the CJR model target price baseline data.
    Final Decision: After consideration of the public comments we 
received, we are finalizing as proposed that PY6 target prices will be 
based on episode baseline data from 2019. We are finalizing our 
proposal with modification to the baseline years used for PYs 7 and 8 
target prices. Specifically, PY7 target prices will be based on episode 
baseline data from 2021, and PY8 target prices will be based on episode 
baseline data from 2022. These policies are finalized at 42 CFR 
510.300(b)(1)(iv) through (vi).
4. Removal of Anchor Factor and Weights and Removal of the Prospective 
Payment System Target Pricing Updates
    Since the CJR model target prices during PYs 1 through 3 were 
calculated using a blend of historical and regional episode costs, the 
primary intent of using anchor weights in the target price calculation 
was to increase the volume of data for statistical predictability 
purposes, particularly for MS-DRG 469 episodes, and to limit the degree 
to which a certain participant hospital's ratio of MS-DRG 469 episodes 
to 470 episodes would skew the pooled historical average episode 
payment, and subsequently the target price. We aimed to incentivize 
participant hospitals based on their hospital-specific inpatient and 
post-acute care (PAC) delivery practices for LEJR episodes. However, to 
incentivize both historically efficient and less efficient hospitals to 
furnish high quality, efficient care in all years of the model, we 
transitioned from primarily hospital-specific to completely regional 
pricing over the course of the 5 performance years (80 FR 73337).
    Since we proposed for PY6 through 8 to use regional episode 
spending data only (no hospital-specific data) to calculate target 
prices, we no longer have the concern that a lack of volume of data for 
certain participant hospitals may limit the predictability of the 
target price calculation, as we did when hospital-specific data were 
incorporated into the target price calculation. Additionally, we no 
longer have the concern that a participant hospital's ratio of MS-DRG 
469 to 470 episodes would skew the pooled historical average episode 
payment, because for PY4 and 5 we removed hospital-specific ratios of 
MS-DRG 469 to 470 episodes from the target price calculation. We 
proposed to continue this in PY6 through 8. Given that we no longer 
have these concerns, we also proposed to stop using the national anchor 
factor calculation and the subsequent regional and hospital weighting 
steps in the CJR model target price calculation method for PY6 through 
8. Additionally, we proposed not to continue the annual updates to the 
target prices that account for changes in the Medicare prospective 
payment systems and fee schedule rates. Since we proposed (as discussed 
in section II.C.6. of this final rule) to add a market trend adjustment 
to the target prices at the time of reconciliation, which will adjust 
for the 2-year percent change in prices at the regional/MS-DRG level, 
we do not believe that the at least twice annual updates to the target 
prices continue to be necessary. To the extent that changes to these 
Medicare prospective payment systems and fee schedule rates influence 
episode costs, the percent difference in episode costs would account 
for that influence and therefore the annual updates would no longer be 
necessary. We sought comment on this proposal.
    The following is a summary of the comments received and our 
responses.
    Comment: A few commenters commented on the proposal to remove the 
anchor factor and weights and updates to the target prices as a result 
of prospective payment system changes, with most comments concerning 
the effect of other aspects of the proposed target price methodology, 
such as the market trend factor. Commenters stated that the existing 
update methodology appropriately accounts for target price changes 
using OPPS and IPPS updates and the CMS discount is sufficient for CMS 
to receive guaranteed savings. A few commenters recommended that the 
CJR model adopt BPCI Advanced's methodology to adjust prospective 
target prices for SNF and other payment system updates.
    Response: As noted in the discussion before Table 6a in section 
IV.C. of this final rule, we proposed to remove the anchor factors and 
weights and updates to CJR model target prices as a result of 
prospective payment system changes from the CJR model payment 
methodology for the 3 years of the extension because they do not always 
account for all payment system changes. Instead of prescribing exactly 
how the CJR model might adjust baseline data for certain payment system 
changes, similar to the original CJR model and BPCI Advanced 
methodologies, we proposed to instead rely on the market trend factor 
to ensure consistency with performance year and baseline costs. We 
anticipate this method will be simpler than the anchor factors and 
weights and less burdensome to monitor than the twice annual updates 
testing in the CJR model PYs 1 through 5. We maintain that the proposed 
market trend factor will adequately account for these factors, weights, 
and updates.
    Final Decision: After consideration of the comments we received, we 
are finalizing our proposal to remove the

[[Page 23518]]

anchor factor and weights and updates to the target prices as a result 
of prospective payment system changes.
5. Changes to Methodology for Determining the High Episode Spending Cap 
Amount in Initial Target Price Calculation
    The high episode spending cap policy was designed to prevent 
participant hospitals from being held responsible for catastrophic 
episode spending amounts that they could not reasonably have been 
expected to prevent, by capping the costs for those episodes. At the 
time the CJR model was implemented, we proposed and finalized a policy 
to set this high cost episode cap at 2 standard deviations above the 
regional mean episode price, both for calculating the target price and 
for comparing actual episode payments during the performance year to 
the target prices. When comparing actual episode payments during the 
performance year to the target prices at reconciliation, episode costs 
exceeding the 2 standard deviation high episode spending cap are not 
included as actual episode payments in the calculation. For example, if 
the high episode cap was set at $30,000, an episode that had an actual 
episode cost of $45,000 would have its costs, for purposes of the 
model, reduced by $15,000 when the cap was applied and therefore, the 
cost for that episode would be held at $30,000. Consequently, assuming 
the target price applicable to the episode was $25,000, the provider 
would be responsible for repaying a specific percentage portion of a 
$5,000 difference rather than for repaying a specific percentage 
portion of a $20,000 difference (where difference is assessed by the 
cost, or capped cost, for the actual episode compared to the target 
price). When we established this policy, we assumed that the episode 
costs in the CJR model would be normally distributed (80 FR 73335). 
With a normal distribution of costs, 95 percent of episodes would have 
costs that are within 2 standard deviations of the mean cost. Under 
this assumption, episodes with costs exceeding 2 standard deviations 
from the mean, would qualify as statistical outliers for high episode 
spending and we therefore set our high episode spending cap at 2 
standard deviations above the regional mean episode price.
    However, in reviewing data from our CJR model experience thus far, 
we have observed three challenges that have limited the ability of our 
current 2 standard deviation methodology to appropriately cap high 
episode spending. First, we have observed that TKA and THA episode 
costs in the CJR model are not normally distributed; as such, less than 
95 percent of episodes have costs that fall within 2 standard 
deviations of the mean. This means that TKA and THA episodes in the CJR 
model exceed the 2 standard deviation amount in their cost more often 
than other clinical episode costs that are distributed approximately 
normally. Second, given the reliance on only regional data for target 
price calculations in PY4, each subset of PY5, and proposed PY6 through 
8, a participant hospital with higher-cost episodes relative to its 
region will benefit more from this capping method since there will be a 
higher probability that its episodes will be capped. This effect was 
not as much of a concern during PYs 1 through 3 since target prices 
were calculated using a blend of hospital-specific and regional costs. 
However, since many of the participant hospitals now participating in 
the CJR model (especially mandatory participants) have higher-cost 
episodes relative to their regions, and target prices are derived from 
regional-only episode data, their performance period episode costs 
would likely exceed the 2 standard deviation high episode spending cap 
amount more often than intended. In other words, assuming a normal 
distribution, we would expect 95 percent of episode costs to be within 
2 standard deviations of the mean episode cost. As we discussed in the 
CJR model November 2015 final rule (80 FR 73336), our original intent 
in establishing the high cost episode capping policy was to mitigate 
the hospital responsibility for episodes with very high Medicare 
spending during the post-discharge 90-day episode period. However, as 
noted previously, TKA and THA episode prices are not normally 
distributed, and more than 2.5 percent of episode costs exceed the 2 
standard deviation maximum threshold. Third, and similar to the first 
challenge that TKA and THA episode costs in the CJR model are not 
normally distributed or otherwise similar to other clinical episodes, 
CJR participant hospital performance period episode costs are not 
normally or otherwise similarly distributed compared to the costs used 
to derive the CJR model target prices. Specifically, while episode 
costs are closer to a normal distribution during the initial target 
price calculation as a result of the larger volume of data in the 
national summary of episode costs (that is, the episode data includes 
non-CJR participating hospitals), the episode costs are not normally 
distributed during reconciliation since episode costs at reconciliation 
are derived from only performance period episode costs (that is, only 
CJR participant hospitals).
    Therefore, the current CJR model methodology that establishes a 
high episode spending cost cap at 2 standard deviations above the mean 
has not reliably produced an episode cost ceiling that applies only to 
very high cost episodes; rather, as a result of the episode 
distribution, the current methodology may result in the inappropriate 
capping of some episode costs. An internal analysis of CJR model 
episode data by CMS showed that in 2016 and 2017 respectively 70 and 83 
percent of CJR participant hospitals had at least one episode capped at 
the high cost episode cap. While we continue to want to protect 
participant hospitals from exposure to very high cost episodes, we need 
to balance that goal with the overarching goal of the CJR model to 
lower costs and increase quality for LEJR procedures.
    As a result, we proposed to change the methodology used in deriving 
the high episode spending cap amount during reconciliation, described 
further in section II.C.5. of this final rule. Since the current CJR 
model high episode spending cost capping methodology used during 
initial target price calculation is the same methodology used during 
reconciliation, we also proposed to change the methodology used in 
deriving the high episode spending cap amount during the initial target 
price calculation to match the proposed methodology used during 
reconciliation. Specifically, we proposed to change our method of 
deriving the high episode spending cap amount applied to initial target 
prices by setting the high episode spending cap at the 99th percentile 
of historical costs. Similar to the current methodology, the high 
episode spending cap calculation would utilize the national summary of 
episode data to calculate the 99th percentile of each MS-DRG and hip 
fracture combination for each region. Total episode costs above the 
99th percentile would be capped at the 99th percentile amount prior to 
calculating target prices for each MS-DRG and hip fracture combination 
for each region. We expect that this method of calculation will result 
in high episode spending caps that more accurately represent the cost 
of infrequent and potentially non-preventable complications for each 
category of episode, which the participant hospital could not have 
reasonably controlled and for which we do not want to penalize the 
participant hospital. We sought comment on this approach.

[[Page 23519]]

    We did not receive comments about the proposed policy to use the 
99th percentile when capping episodes prior to calculating the target 
prices. We are finalizing this provision without modification.

C. Reconciliation

1. Background
    Currently, for PY1 through 4 and for each subset of PY5, CJR model 
payments are reconciled twice after the close of a performance year. At 
reconciliation, performance year episode costs are computed for each 
participant hospital for each MS-DRG and hip fracture combination and 
these costs are then capped at 2 standard deviations above the regional 
mean episode price. Each participant hospital's composite quality score 
for combined performance on the CJR model quality measures, 
specifically, the total hip arthroplasty/total knee arthroplasty (THA/
TKA) Complications measure and HCAHPS Survey measure, and voluntary 
submission of patient-reported outcomes and limited risk variable data, 
is then calculated. While all participant hospitals in the CJR model 
are assigned a target price with a quality discount factor of 3 
percent, the quality discount applicable to a specific participant 
hospital at reconciliation may be lowered to 2 percent in instances 
where the hospital earns a quality category of good, or 1.5 percent in 
instances where the hospital earns a quality category of excellent. 
Based on reconciliation results from the first 2 performance years of 
CJR, roughly 18 percent of CJR participant hospitals achieved quality 
scores of `Excellent,' around 60 percent achieved `Good,' around 12 
percent achieved `Acceptable' and less than 10 percent were deemed 
`Below Acceptable.' An initial reconciliation is performed using claims 
data available 2 months after the end of the performance year, and a 
final reconciliation is performed 1 year later, using claims data 
available 14 months after the end of the performance year.
    At reconciliation, all participant hospitals that achieved LEJR 
actual spending below the target price and achieved a minimum composite 
quality score were eligible to earn up to 5 percent of the difference 
between their target price and their actual episode costs in PYs 1 and 
2; 10 percent of this difference in PY3; and 20 percent in PY4 and each 
subset of PY5. The limits are referred to as ``stop-gain limits'' (80 
FR 73401). Any net payment reconciliation amount (NPRA) greater than 
the proposed stop-gain limit would be capped at the stop-gain limit.
    Conversely, participant hospitals with LEJR episode spending that 
exceeds the target price at reconciliation are financially responsible 
for the difference to Medicare up to a specified repayment, or a 
``stop-loss limit.'' For most participant hospitals, the stop-loss 
limit was 5 percent of the difference between their target price and 
their actual episode costs in PY2; 10 percent for PY3; and 20 percent 
for both PY4 and each subset of PY5. For participant hospitals that are 
rural hospitals, Medicare-dependent hospitals, rural referral centers, 
and sole community hospitals, the stop-loss limit was 3 percent for 
PY2; and 5 percent for PY3 through PY4, and each subset of PY5. Any 
reconciliation repayment amount that exceeds the proposed stop-loss 
limit would be capped at the stop-loss limit.
    We implemented a parallel approach for the stop-gain and stop-loss 
limits to provide proportionately similar protections to CMS and to 
participant hospitals, as well as to protect the health of 
beneficiaries. We believe it is appropriate that as participant 
hospitals increase their financial responsibility, they can similarly 
increase their opportunity for additional payments under this model. We 
also believe that these changes facilitate participants' ability to be 
successful under this model and allow for a more gradual transition to 
financial responsibility under the model.
2. Overview of Changes to Reconciliation Process
    In the proposed rule, we proposed changes to the CJR model 
reconciliation process that are intended to reduce administrative 
burden, to adjust target prices for beneficiary-specific risk elements, 
to better recognize participant providers with good and excellent 
composite quality scores, and to improve our ability to account for 
changes in payment policy and market trends in utilization. 
Additionally, we proposed changes to the reconciliation process that 
parallel the changes we propose to the target price calculations 
discussed in section II.B. of this final rule.
    Beginning with PY6, we proposed to conduct one reconciliation per 
CJR model performance year, which would be initiated 6 months following 
the end of a CJR model performance period. This change is intended to 
reduce the administrative burden of a second reconciliation for 
Medicare and CJR participant hospitals, and it is driven by internal 
analyses, discussed in section II.C.3. of this final rule, that 
indicate the 6 months after an episode ends is sufficient time period 
to capture episode spending data. However, we proposed that the current 
CJR model post-episode spending policy, codified at Sec.  510.305(j)(2) 
and Sec.  510.2, would still apply during PY6 through 8. Additionally, 
we proposed conforming changes to Sec.  510.305 such that the PY4 and 5 
stop-loss limits and stop-gain limits of 20 percent would continue in 
place for each of PY6 through 8.
    Additionally, in an effort to recognize the greater needs of 
certain beneficiaries that are beyond a participant hospital's control, 
we proposed to incorporate a risk adjustment factor for each episode's 
target price during reconciliation for PY6 through 8. Specifically, as 
discussed in section II.C.4. of this final rule, we would adjust the 
target price at reconciliation using two patient-level risk factors, 
the CJR HCC count risk adjustment factor and the age bracket risk 
adjustment factor.
    Further, as mentioned in section II.B.5. of this final rule, we 
proposed to change the methodology used in deriving the high episode 
spending cap amount during reconciliation. For PY6 through 8 of the 
proposed extension, at reconciliation we would determine the high 
episode spending cap amount by calculating the 99th percentile of 
regional mean episode spending and cap episodes at that amount, in 
order to remove the effect of high-cost statistical outliers on average 
costs. We proposed this change since we have observed that CJR model 
episode costs are not normally distributed, as discussed in section 
II.B.5. of this final rule, and a greater number of CJR model episodes 
have exceeded the high episode spending cap amount than we intended.
    We also proposed to add a market trend factor to adjust for recent 
variations in the underlying structure of the market. Specifically, we 
proposed that the market trend factor would be the regional/MS-DRG mean 
cost for episodes occurring during the performance year divided by the 
regional/MS-DRG mean cost for episodes occurring during the target 
price base year. For example, at the reconciliation for PY6 which will 
occur at the end of June of 2023 after allowing for 6 months of claims 
runout, we will compute the regional/MS-DRG mean cost for episodes 
occurring during the performance year (October 1, 2021 through December 
31, 2022) and would divide that by the regional/MS-DRG mean cost for 
episodes that occurred during calendar year 2019 as the target prices 
for PY6 will be set using 2019 data. We note that we will make a minor 
adjustment to this methodology when we calculate PY6 target prices for 
MS-

[[Page 23520]]

DRGs 521 and 522, in order to align the methodology we proposed in the 
February 2020 rule with the addition of these new MS-DRGs to the CJR 
episode definition in the November 2020 IFC. In those instances only we 
will adjust the IPPS portion of episode costs for baseline episodes 
initiated by MS-DRG 469 and 470 with fracture, as described in section 
II.A.2. of this final rule. This adjustment will consist of multiplying 
those IPPS costs by the ratio of the MS-DRG 521 and 522 weights (which 
are applicable to performance period episodes) to the MS-DRG 469 and 
470 weights that were applicable in the baseline period. We will make 
this adjustment prior to the application of the market trend factor for 
PY6 target prices for episodes initiated by MS-DRGs 521 and 522. This 
adjustment will result in target prices that more accurately reflect 
the methodology we proposed in the February 2020 proposed rule, which 
assumed that the target price for the MS-DRG and fracture status of 
each episode in the performance period would be based on baseline 
episodes with the same MS-DRG and fracture status.
    Lastly, we proposed changes to the effective discount factor and 
applicable discount factor in Sec.  510.315, to better recognize 
participant providers in the `Good' and `Excellent' CJR model composite 
quality score categories. For PY6 through 8, we proposed to continue to 
use 3 percentage points as the discount factor applied during 
calculation of regional target prices. However, we proposed to increase 
an individual participant hospital's potential quality incentive 
payment; that is, we proposed a larger reduction in the discount factor 
based on the composite quality score. The opportunity for this larger 
reduction in the discount factor was proposed because we anticipate 
that the proposed changes to the target price methodology, discussed in 
section II.B. of this final rule, will better align the target prices 
with actual spending during a performance year. While more accurate 
initial target prices will enhance stability for participant hospitals 
at reconciliation, it also means the quality adjusted target price and 
actual episode spending will align more closely over time and we want 
to ensure that we continue to recognize high quality participant 
hospitals by giving them a larger portion of the achieved savings. As a 
result, for PY6 through 8, we proposed a 1.5 percentage point reduction 
to the applicable discount factor for participant hospitals with 
``good'' quality performance and a 3-percentage point reduction to the 
applicable discount factor for participant hospitals with ``excellent'' 
quality performance.
    The following is a summary of the comments received and our 
responses.
    Comment: A commenter provided general feedback on the proposed 
changes to the reconciliation process and supported CMS' proposed 
policy to maintain the 20 percent stop-loss and stop-gain limit amounts 
from PYs 1 through 5 of the CJR model, noting that this policy is 
consistent across other models and will assist in the model evaluation 
process.
    Response: We recognize consistent policies across CMS APMs can aid 
model participants as well as CMS evaluators and we have adopted 
policies that align with other APMs, such as the policy in this final 
rule to eliminate the 50 percent cap on gainsharing payments, 
distribution payments, and downstream distribution payments, where 
possible and appropriate. We appreciate the commenters' support for the 
CJR model stop-loss and stop-gains policy amounts that align with the 
amounts with other models, such as the BCPI Advance model.
    Comment: MedPAC suggested that CMS should focus on changes to the 
model that could generate net savings for the Medicare program instead 
of redistributing all of them back to providers, such as increasing the 
percentage of losses for which hospitals are responsible.
    Response: CMS appreciates MedPAC's suggestions to generate 
additional savings for the Medicare program by increasing the stop-loss 
limit. Many of the changes CMS proposed to the CJR model payment 
methodology for PY6 through 8 are intended to be improvements to the 
original methodology that will increase the probability for model 
savings. While CMS could design a payment methodology that attributed a 
much larger portion of savings to the Medicare program by increasing 
the stop-loss limit amount, we must also balance the administrative 
burden and investments needed by participating hospitals to be 
successful under the model, and thus proposed to continue the stop-loss 
limit from PYs 1 through 5 for PYs 6 through 8 that is intended to 
ensure that CJR participant hospitals are still capable of achieving a 
certain level of savings for themselves in the model.
3. Changes to Frequency and Timing of Reconciliation
    As noted in section II.B.1. of this final rule, following the 
completion of performance years 1 through 4 and each subset of 
performance year 5, participant hospitals that achieve episode spending 
below the applicable target price and achieved a minimum composite 
quality score have been eligible to earn a reconciliation payment from 
Medicare for the difference between the target price and actual episode 
spending, up to a specified cap (see 80 FR 73337 for a detailed 
discussion of CJR model episode pricing). The retrospective process 
reconciles a participant hospital's actual episode payments against the 
target price 2 months after the end of each of performance years 1 
through 4 and the first subset of performance year 5. More 
specifically, we use claims data that is available 2 months after the 
end of a performance year and carry out the NPRA calculation described 
in Sec.  510.305 to make a reconciliation payment or repayment amount, 
as applicable. Fourteen months after the end of each of performance 
years 1 through 4 and performance year subset 5.1, CMS performs an 
additional calculation, using claims data available at that time, to 
account for final claims run-out and any additional episode 
cancelations due to overlap between the CJR model and other CMS models 
and programs, or for other reasons as specified in Sec.  510.210(b). 
The subsequent reconciliation calculation is applied to the previous 
calculation of NPRA for a performance year to ensure the stop-loss and 
stop-gain limits are not exceeded for a given performance year. The 
difference between the initial and final reconciliation amount from 
this calculation, if different from zero, is calculated and added to 
the NPRA for the subsequent performance year in order to determine the 
net reconciliation payment or repayment amount. CMS performs these same 
calculations for performance year subset 5.2. However, with the initial 
reconciliation occurring 5 months after the end of performance year 
subset 5.2 and the final reconciliation occurring 17 months after the 
end of performance year subset 5.2.
    When we first adopted the process to perform a reconciliation 
calculation 2 months after the conclusion of a performance year, with a 
subsequent reconciliation calculation 12 months later, the policy 
reflected the assumption that it was necessary to allow sufficient time 
for routine monitoring, review, and adjustment (80 FR 73386). However, 
internal analyses and monitoring of CJR model claims data from PYs 1 
and 2 indicated that the full 14 months is not necessarily required to 
sufficiently capture claims run out and overlap with other models.

[[Page 23521]]

For example, the number of episodes attributed to PY1 increased by 
slightly less than 1 percent from the initial to subsequent 
reconciliation and total reconciliation payments for PY1 decreased by 
about 6 percent between the initial and subsequent reconciliation. The 
PY2 subsequent reconciliation process showed a similar trend; that is 
the attributed episode count increased by about 1 percent and total 
reconciliation payments decreased by around five percent. While we are 
not able to accurately predict or quantify the dollar impact shifts 
between the initial and final reconciliations for individual CJR 
participant hospitals, anecdotally, based on reconciliations of the 
first 2 performance years of the CJR model, some CJR participant 
hospitals owed over $100,000 because their initial reconciliation 
payments were too high relative to their final reconciliation payments. 
Other CJR participant hospitals who ultimately saw their reconciliation 
payments increase from initial to final reconciliations increased by 
amounts under $60,000.
    In the proposed rule, we stated that we recognized shifting 
reconciliation amounts, especially those that result in unanticipated 
repayments, could be problematic for some providers. By allowing a 
longer period for claim run out prior to initiating the first and only 
reconciliation, we stated our belief that we could provide a more 
predictable and stable reconciliation process for CJR participant 
hospitals without significantly impacting the accuracy of the 
reconciliation payment and/or repayment amounts. Regarding the impact 
of this change on other models and programs that use CJR reconciliation 
data to perform their own overlap calculations, we stated that we did 
not anticipate that the change to the frequency and timing of the CJR 
model reconciliation would create new difficulties for CMS Innovation 
Center models and the Shared Savings Program when they account for 
overlap with CJR. Specifically, in regards to the Shared Savings 
Program, we noted that the Shared Savings Program only uses finalized 
data in its financial reconciliation calculations, and CJR initial 
reconciliation data are not considered final.
    We proposed to conduct one reconciliation for each of PY6 through 
8, 6 months following the end of a performance year. For instance, for 
PY6 (which includes all CJR model episodes ending on or after October 
1, 2021 and on or before December 31, 2022), we proposed to reconcile a 
participant hospital's CJR model actual episode payments against the 
applicable target prices one time only, based on claims data available 
on July 1, 2023. As discussed previously, our internal analyses 
indicate the timing of this proposed reconciliation methodology will 
allow enough time to adequately capture episode costs. This methodology 
would also reduce the administrative burden associated with an extra 
reconciliation calculation on CMS and participant hospitals. 
Additionally, we believe this new methodology will enhance participant 
hospitals' ability to predict the outcome of reconciliation 
calculations, since they will no longer need to include unanticipated 
adjustments for prior year performance.
    We also proposed that current CJR model post-episode spending 
policy, codified at Sec.  510.305(j)(2) and Sec.  510.2, would still 
apply during PYs 6 through 8. Specifically, we proposed that we would 
maintain the policy that 30-day post-episode spending for episodes 
attributed to all IPPS hospitals would be calculated to determine the 
value that is 3 standard deviations greater than the regional average 
30-day post-episode spend and to determine if a participant hospital 
has excessive average 30 day post-episode spending. The spending amount 
exceeding 3 standard deviations above the regional average post-episode 
payments for the same performance year is subtracted from the net 
reconciliation or added to the repayment amount for the subsequent PYs 
1 through 4. While this calculation is performed at the subsequent 
reconciliation for PYs 1 through 4 and each subset of PY5, we note that 
internal analyses and monitoring of CJR model claims data from PYs 1 
and 2 indicate that the full 14 months is not necessarily required to 
sufficiently capture claims run out. Unlike the high cost episode 
spending cap policy, the 30-day post-episode spending policy only 
assesses episode costs 30 days following the end of an episode; this 
distribution is more ``normal'' than the high cost episode cap 
distribution that assesses the full 90-day episode costs. There have 
been few issues with the post-episode spending methodology to date.
    The following is a summary of the comments received and our 
responses.
    Comment: A number of commenters supported the proposal to move from 
2 reconciliations, conducted 2 months and 14 months after the end of 
the performance year, to one reconciliation, conducted 6 months after 
the end of the performance year. Commenters stated their belief that 6 
months was an adequate period of claims run-out to capture episode 
costs and that the change to one reconciliation would significantly 
reduce administrative burdens on hospitals. A commenter estimated that 
CMS would save $240,958 by moving to one reconciliation period. A 
commenter stated that this change would simplify participating 
hospitals' communication with the physicians with whom they have 
gainsharing agreements. Another commenter pointed out that this change 
would reduce the potential for secondary reconciliations that result in 
a participant owing a repayment, which would provide more certainty for 
providers.
    Response: We appreciate the commenters' support for our proposal to 
move in PY6 from 2 reconciliations for each performance year to one 
reconciliation for each performance year. We agree with the commenters 
that 6 months is an adequate period of claims runout, and that this 
change will both reduce administrative burden on participants and also 
eliminate the uncertainty of whether the second reconciliation would 
result in the participant owing a repayment. We also agree that moving 
to one reconciliation period would result in a net savings to CMS, as 
the reconciliation calculation would include only 1 performance year's 
worth of data which would simplify the reconciliation process.
    Comment: Multiple commenters stated that they generally supported 
the change to one reconciliation, but also had concerns about the 
change. Multiple commenters requested that we consider strategies to 
mitigate cash flow issues that could occur during the initial 
transition. A commenter requested additional clarity on how the 
transition would occur. Multiple commenters expressed their concern 
about the lack of a timely feedback loop to providers, stating that 
there is a long time between the beginning of the performance year and 
the reconciliation. A commenter requested that CMS develop a tool for 
participants that would take into account the adjustments CMS makes at 
reconciliation, such as application of the risk factor multipliers, 
using the best available data. They stated their belief that this would 
help participants gauge their performance, with the understanding that 
the results would be estimates and would vary from the final 
reconciliation results. Another commenter requested details on our 
planned approach for claims data sharing.
    Response: In response to commenters' concerns about cash flow 
issues resulting from the change from 2 reconciliations to one 
reconciliation, we point out that we have historically

[[Page 23522]]

conducted one reconciliation process in each performance year, issuing 
combined results from the initial reconciliation of the most recently 
completed performance year and the final reconciliation from the 
previous performance year. Therefore, the frequency of reconciliation 
processes proposed for PYs 6 through 8 will align with the commenters' 
experience, but whereas prior reconciliation processes represented 2 
different performance years, beginning in PY6 that process will only 
represent 1 performance year. Additionally, as a result of the 
extension of PY5 through September 30, 2021 and the division of PY5 
into two subsets for purposes of reconciliation (PY5.1 and PY5.2), we 
will perform both the subsequent reconciliation of PY5.2 and the single 
reconciliation of PY6 in calendar year 2023. Rather than a transition 
year when the final reconciliation for the previous performance year is 
delayed, participants will receive two separate reconciliation reports 
in the same calendar year, thus mitigating concerns that a delay in 
reconciliation during the transition year could negatively impact cash 
flow or prevent timely feedback in their reconciliation report. 
Finally, we remind commenters that participants in the CJR model 
continue to bill and be paid through normal Medicare FFS processes 
throughout the model for Part A and Part B services furnished to 
beneficiaries during a CJR model episode.
    In response to the commenter's general request for clarification 
about the transition from two reconciliations to one reconciliation, we 
wish to further clarify how certain policies that were previously 
applied at the subsequent reconciliation will be applied at the single 
reconciliation for PYs 6 through 8. As described previously in section 
II.B.2., certain overlap policies will continue to be applied at the 
single reconciliation for PYs 6 through 8, but the ACO overlap 
adjustment calculation, which we proposed in Sec.  510.305(j)(1) to 
continue applying to PYs 6 through 8, will no longer be feasible 
because the necessary data will not be available six months after the 
performance year. For this reason, we are not finalizing our proposed 
amendments to Sec.  510.305(j)(1) (though we are finalizing the changes 
we adopted in the November 2020 IFC). However, we will be able to apply 
the overlap policy described in Sec.  510.305(i)(1), which cancels 
certain episodes due to overlap between the CJR model and other 
specified CMS models and programs, at the single reconciliation, so we 
have added Sec.  510.305(m)(i)(v) to specify that we will apply that 
overlap policy at the single performance year reconciliation for each 
of PYs 6 through 8.
    Similarly, we proposed in Sec.  510.305(j)(2) to continue our 
policy of conducting a post-episode spending calculation in PYs 6 
through 8. However, the post-episode spending calculation has 
previously been conducted at the subsequent reconciliation in order to 
allow additional time for claims run-out beyond the 2 months that 
precede the initial reconciliation. For PYs 6 through 8, we believe 
that the six month interval between the end of the performance year 
will provide sufficient time for claims run-out, given that the 30-day 
post-episode spending period for the last episodes in a given 
performance period will end on January 30 of the following year, 
leaving five additional months of claims run-out before the single 
reconciliation. Rather than finalize our proposal to incorporate the 
post-episode spending policy for PYs 6 through 8 into Sec.  
510.305(j)(2), we have instead added Sec.  510.305(m)(i)(vi) to clarify 
that the post-episode spending calculation will take place at the 
single reconciliation for PYs 6 through 8.
    Since the target price methodology will differ in a number of ways 
between PY subset 5.2 and PY 6, we are also clarifying how we will 
treat episodes that begin during PY 5.2 but end, and are therefore 
reconciled, in PY 6. In Sec.  510.300(a)(3) we stated that episodes 
that straddled performance years or performance year subsets would be 
subject to the target price applicable to the start date of the 
episode. This means that there will almost certainly be CJR episodes 
that have a performance year 5.2 target price but are reconciled in 
performance year 6. In the proposed rule, we stated at Sec.  510.301 
that beginning in PY 6, we would further adjust the target price 
computed under Sec.  510.300 for risk and market trends to arrive at 
the reconciliation target price amount. However, PY 5.2 target prices 
were designed to apply to inpatient episodes only, incorporating 
adjustments for MS-DRG and fracture status without additional 
beneficiary-level risk adjusters, and incorporating a prospective 
update factor rather than a retrospective market trend adjustment. 
Therefore, we believe it would not be appropriate to further adjust a 
PY 5.2 target price for beneficiary-level risk factors and a 
retrospective market trend at the PY 6 reconciliation. In order to be 
consistent with our policy at Sec.  510.300(a)(3), but also accommodate 
the difference in target price calculation methodology between PY 5.2 
and PY 6, we are modifying our proposed text at Sec.  510.301 to 
specify that episodes subject to a PY 5.2 target price but reconciled 
in PY 6 would not have their target price further adjusted for risk and 
market trends.
    In response to the commenters' concerns about timely feedback on 
their model performance, we note that providing two reconciliation 
reports in the transition year also mitigates concerns that a delay in 
reconciliation would prevent participant hospitals from receiving 
timely feedback in their reconciliation report. We also point out that 
we continue to provide a monthly claims data feed including all claims 
for services included in a given episode. This provides timely feedback 
that can be used by participants to identify cost drivers, identify 
opportunities for greater care coordination, and gauge their 
performance in the model. Further, we will be incorporating claims data 
for outpatient episodes, CJR HCC count, participant age bracket, and 
dual eligibility status, as well as providing the regression 
coefficients that will be used at reconciliation to risk adjust target 
prices at the episode level. We believe that these data will provide 
the necessary information to help participants gauge their performance 
in the model and perform preliminary estimates of the adjustments that 
will be made at reconciliation.
    Comment: A few commenters recommended that CMS maintain the current 
practice of performing two reconciliations for each performance year. A 
commenter stated their concern that the proposed revised process will 
compromise physicians' engagement in care redesign plans and follow-up 
actions to achieve the objectives of the plan. Another commenter stated 
that the change would result in payments being further removed from 
physician behavior. They stated their concern that this could result in 
incentive payment delays and diminish the impact of such payments on 
physician behavior.
    Response: We acknowledge that the time lag between when physician 
services are performed and when reconciliation reports and potential 
reconciliation payments are received may be a challenging aspect of the 
CJR model. However, we disagree that the change to one reconciliation 
will impact physician engagement significantly more than the current 
reconciliation process does. In the initial years of the model, the 
first reconciliation involved episodes that had ended between 2 and 14 
months prior to when the claims data were pulled, with an additional 2 
to 4 months of time to complete the

[[Page 23523]]

reconciliation calculations and deliver reconciliation reports, and 
allow a 45-day window for participant hospitals to appeal their results 
before we finalized them. This resulted in reconciliation payments 
being made, or repayments being owed, from 6 to 18 months after the 
episodes had ended, dependent on how early or late in the year the 
episodes ended. The results of the initial reconciliation would not be 
finalized until an additional year afterwards. The new reconciliation 
policy effective PY6 will consist of one reconciliation of episodes 
that ended 6 to 18 months prior to when the claims data are pulled, 
with reconciliation payments made, or repayments owed, 10 to 22 months 
after the episodes had ended. Although this represents a four month 
shift, we note that physicians will benefit from knowing that 
reconciliation results, while arriving a few months later than they 
currently do, will not be subject to any additional reconciliation in 
the future. We encourage participants who have found effective ways to 
engage with physician participants to continue these efforts.
    Final Decision: After consideration of the comments we received, we 
are finalizing our proposal to move to one reconciliation for each 
performance year, beginning 6 months after the end of the performance 
year. However, for greater clarity, we are not finalizing our proposed 
changes to Sec.  510.305(j)(1) and (2) to extend previous overlap 
calculations and post-episode spending calculations to PYs 6 through 8, 
since they were previously applied at the subsequent reconciliation. As 
discussed above, we are adding Sec.  510.305(m)(1)(v) to address 
overlaps for PYs 6 though 8. We are adding Sec.  510.305(m)(1)(vi) to 
specify that the post-episode spending calculation will be applied at 
the single reconciliation for PYs 6 through 8. Additionally, we are 
modifying our proposed text at 510.301 to specify that episodes that 
are subject to a PY 5.2 target price but are reconciled in PY 6, will 
not be subject to the additional risk and market trend adjustments that 
will otherwise apply at the first reconciliation for PY 6.
4. Additional Episode-Level Risk Adjustment
    When we originally proposed the CJR model pricing methodology, we 
proposed to provide each hospital with a separate target price for 
episodes initiated by MS-DRG 469 versus MS-DRG-470, because MS-DRGs 
under the IPPS are designed to account for some of the clinical and 
resource variations that exist and that impact hospitals' costs of 
providing care (80 FR 73338). Specifically, MS-DRG 469, which focuses 
on costlier and complex hip and knee procedures involving patients with 
major complications and comorbidities, has a higher relative weight 
than MS-DRG 470, which ensures that the Medicare payment for MS-DRG 469 
is higher than that for MS-DRG 470. However, in response to comments 
requesting further risk adjustment, we finalized a policy to risk 
adjust target prices based on the presence of hip fractures (80 FR 
73339). We stated our belief that adding hip fracture status to our 
risk adjustment approach would capture a significant amount of patient-
driven episode expenditure variation. The impact of hip fractures on 
inpatient costs associated with a hip replacement was acknowledged by 
CMS' decision to create two new MS-DRGs (521 and 522) for hip 
replacements in the presence of a primary hip fracture (85 FR 58432). 
We incorporated these new MS-DRGs into the CJR model episode definition 
as of October 1, 2020 via the November 2020 IFC. Thus, we have been 
providing four separate target prices to each participant hospital. 
Prior to October 1, 2020, these target prices were based on the 
combination of the MS-DRG to which the IPPS admission was grouped (469 
or 470) and whether or not the patient had a hip fracture. Since 
October 1, 2020, when MS-DRGs 521 and 522 were implemented, we no 
longer need to stratify MS-DRG 469 and 470 episodes by fracture status, 
as episodes with a hip fracture are assigned instead to one of the two 
new MS-DRGs.
    Given our proposal to specify that permitted outpatient LEJR 
procedures can initiate a CJR model episode, we recognize that 
additional risk adjustment is needed in order to account for 
variability within the four categories of target price. As we note 
previously in section II.A. of this final rule, we recognize that a 
single blended target price for the MS-DRG 470 category in particular 
could potentially underestimate spending on some inpatient episodes and 
likewise, could potentially overestimate spending on some outpatient 
episodes. This will theoretically average out across all MS-DRG 470 
without hip fracture episodes at the regional level during 
reconciliation, but given the fact that participant hospitals' ratio of 
inpatient-to-outpatient cases will vary, we proposed to make an 
episode-specific adjustment to each target price.
    The CJR model policy of adjusting target prices for MS-DRG 469 and 
470 based on the presence of hip fracture was originally intended to 
allow us to include beneficiaries who receive LEJR procedures due to 
hip fractures in the CJR model, while acknowledging their typically 
greater health care needs by providing a target price that is based on 
payment for services furnished in the historical CJR model episode data 
for Medicare beneficiaries with hip fractures in order to account for a 
significant amount of beneficiary-driven episode expenditure variation. 
With the same goal in mind of recognizing the greater needs of certain 
beneficiaries that are beyond a participant hospital's control, we 
proposed an additional risk adjustment methodology for PYs 6 through 8. 
We note that in exploring options for a risk adjustment methodology, we 
considered a number of factors that are not included in the proposed 
methodology because they were not strong predictors of episode cost, 
might result in unintended provider efficiency disincentives, were 
overly complex to calculate or administer, had limited credibility or 
quality of the underlying data sources, and/or conflicted with overall 
bundled payment initiatives. The factors we considered include: Dual 
eligibility (beneficiaries enrolled in Medicare Part A and/or Part B 
and receiving full Medicaid benefits); discharge status (the care 
setting for the beneficiary post procedure); joint region (hip, knee, 
or ankle); gender; CMS-HCC risk scores (both community and 
institutional); rural/urban designation of the participant hospital; 
clinical setting (inpatient or outpatient); rehospitalization rate 
(presence of hospital admission post procedure); and indices of social 
determinants of health at the ZIP Code level (for example, participant 
hospitals receiving a certain level of Medicare disproportionate share 
payments). After conducting a variety of analyses and regressions, we 
proposed to incorporate the additional risk adjustment into the CJR 
model pricing based on CMS-HCC condition count and beneficiary age.
    The first part of the proposed methodology takes into account the 
total number of clinical conditions per beneficiary by assessing the 
count of CMS-HCC conditions, referred to as the CJR HCC count risk 
adjustment factor. While we proposed to name this risk adjustment 
factor the ``CMS-HCC condition count'' in the proposed rule, we are 
updating the term in this final rule to be the ``CJR HCC count risk 
adjustment variable'' to avoid confusion with other applications of the 
CMS-HCC data. This approach parallels the risk adjustment model used in 
the Medicare Advantage program that began with Medicare Advantage 
payments in 2020, which include variables that take

[[Page 23524]]

into account the number of conditions a beneficiary may have and makes 
an adjustment as the number of conditions increase in order to 
implement section 1853(a)(1)(I)(i)(I) of the Act (42 U.S.C. 1395w-
23(a)(1)(I)(i)(I)), as added by section 17006(f) of the 21st Century 
Cures Act. Similarly, we chose to include risk adjustment variables 
that account for the total number of conditions of a beneficiary 
initiating a CJR model episode.
    The count variables for CJR HCC count risk adjustment in the CJR 
model would be a series of binary, yes/no variables, meaning that a 
beneficiary does or does not meet the criteria for having a given 
number of CMS-HCC conditions. We proposed to use five CJR HCC count 
variables, representing beneficiaries with zero, one, two, three, or 
four or more CMS-HCC conditions. We proposed to estimate a coefficient 
from the subgroup of beneficiaries in the sample with the specific 
count of conditions for each count variable (as described later in this 
section). For example, all beneficiaries with two CMS-HCC conditions 
would receive a coefficient that is estimated independently of the 
coefficient for beneficiaries with zero, one, three or four conditions. 
The coefficient for the two CJR HCC count variable would represent the 
expected marginal cost of having any two CMS-HCC conditions, as 
compared to having zero CMS-HCC conditions.
    The second part of the proposed risk adjustment methodology is 
meant to account for average anticipated episode costs associated with 
the age of a CJR beneficiary. Similar to the strategy for incorporating 
the CJR HCC count, we would create binary, yes/no variables for 
beneficiaries that fall into certain age ranges. We proposed four age 
variables for the risk adjustment methodology to represent 
beneficiaries aged less than 65 years, 65 years to 74 years, 75 years 
to 84 years, and 85 years or more, based on the patient's age at the 
time the HCC files were created. We proposed to estimate a coefficient 
from the subgroup of beneficiaries in the sample in each age range (as 
described further later in this section). We proposed that, for 
applying the coefficient to a given reconciliation target price at 
reconciliation, we would select the age bracket coefficient based on 
the patient's age on the date of admission for the anchor 
hospitalization or the date of the anchor procedure.
    The CMS-HCC risk adjustment model is prospective; it uses a profile 
of major medical conditions in the base year, along with demographic 
information (for example, age, sex, Medicaid dual eligibility, 
disability status), to predict Medicare expenditures in the next year. 
It is calibrated on a population of FFS beneficiaries entitled to Part 
A and enrolled in Part B, because CMS has complete Medicare expenditure 
and diagnoses data for this population. The proposed risk adjustment 
method for the CJR model would also be prospective in that it would use 
the most recently available data to predict the average expected 
adjustment in target price relative to the two risk adjustment 
variables for future performance years. Given the timing of this rule 
and the time to receive and process CMS-HCC condition count data, we 
proposed utilizing beneficiary CMS-HCC condition count and age data 
from a baseline of January 1, 2019 to December 31, 2019 to calculate 
coefficients for both risk adjustment variables for PY6. Similarly, we 
proposed utilizing beneficiary CMS-HCC condition count and age data 
from January 1, 2020 to December 31, 2020, and from January 1, 2021 to 
December 31, 2021 to calculate coefficients for both risk adjustment 
variables for PYs 7 and 8, respectively. While this should 
appropriately capture CMS-HCC condition count data for almost all 
beneficiaries, for any beneficiaries with missing CMS-HCC condition 
count data we would apply a CJR HCC count risk adjustment coefficient 
of one, so that their missing CMS-HCC condition count would neither 
adjust risk up nor down from the average regional target price based in 
the calculation of the coefficient.
    For PYs 6 through 8, coefficients for the risk adjustment variables 
would be calculated prospectively, prior to the beginning of each 
performance year, using a linear regression model. In essence, this 
regression model approach would allow us to estimate the impact of CJR 
HCC count and age bracket on the episode cost of an average 
beneficiary, based on typical spending patterns for a nationwide sample 
of beneficiaries with a given number of CMS-HCC conditions and within a 
given age bracket. We proposed an exponential model, with the dependent 
variable equal to the ratio of the individual episode cost to the 
regional target price, since it will make it less difficult and simpler 
to estimate the proportional increase or decrease for each independent 
variable that can be directly applied to adjust the regional target 
prices. In statistical terms, linear regression models assume a linear 
relationship between a dependent variable and one or more explanatory 
variables, and the associated statistical inference typically reflects 
an assumption of a normal distribution of the error variance (that is, 
the discrepancy between observed values of the dependent variable and 
what would be predicted by the model). As we stated in section II.B.5 
of this final rule, when costs are normally distributed, 95 percent of 
the costs are truly within 2 standard deviations of the mean, with only 
5 percent of episodes having costs that are much higher than the 
average cost or much lower than the average cost. As we have previously 
observed, TKA and THA episode costs in the CJR model are not normally 
distributed; that is, less than 95 percent of the costs fall within 2 
standard deviations of the mean. This means that TKA and THA episode 
costs in the CJR model will inherently exceed the 2 standard deviation 
threshold more often than other clinical episode costs that are 
distributed normally.
    Exponential models, such as the risk adjustment model we proposed, 
are commonly estimated by transforming the equation to logs through 
logarithmic transformation. In transforming our proposed exponential 
model, the dependent variable becomes the difference in the logs of the 
individual episode costs and the applicable regional MS-DRG target 
prices and the proportional increases or decreases for each independent 
variable are obtained by exponentiating the regression coefficients of 
the log-transformed model.
    Estimating the logged version of such a model could be problematic 
when de-transforming the logged results to their original form (that 
is, dollars), but this concern is not relevant since we are simply 
proposing to utilize the ratios from the logged version of the model. 
Further, we believe that the MS-DRG target pricing differentiation 
already explains a portion of the cost differences in CJR model 
episodes. Therefore, rather than using the log of the episode cost, we 
proposed to use the differential between the log of the episode cost 
and the log of the episode target price so as to focus only on the cost 
difference not already reflected in the existing target prices.
    Specifically, for each episode in the national sample, grouped into 
its appropriate category based on 36 combinations of the 9 regions and 
the 4

[[Page 23525]]

MS-DRG categories, we would subtract the log transformed episode target 
price for that category from each log transformed standardized episode 
cost.\8\ We note that prior to computing the log values of the episode 
costs, we ranked the episode costs and determined the 99th percentile 
(high episode cost cap) amount for each region/MS-DRG combination. We 
then replaced the actual cost amount for each episode that exceeded the 
applicable 99th percentile amount with that 99th percentile amount, 
consistent with our proposal to update the methodology used in deriving 
the high episode spending cap amount.\9\ We note that we purposely 
applied the high cost episode cap prior to computing the regression as 
we are looking to compute a risk adjustment for the dollars involved in 
the model. Since we have a high episode cost cap such that no episode 
will ever cost more than the cap amount, we wanted to ensure the risk 
adjustment coefficient explained the difference between the capped 
costs and the target price so we could adjust the targets 
appropriately. Then, we would regress, or determine the strength of the 
relationship between each risk adjustment factor and episode costs, 
these amounts (the costs from episodes of care furnished to any 
eligible beneficiary in FFS Medicare from the applicable baseline 
calendar year who is entitled to Part A and enrolled in Part B and has 
an episode triggered by a claim for a MS-DRG 469, 470, 521 or 522, or 
permitted outpatient TKA/THA CPT code) onto their CJR HCC count and age 
bracket. The resulting coefficients associated with CJR HCC count and 
age bracket (after exponentiating the coefficients in order to 
``reverse'' the logarithmic transformation we performed earlier on 
episode costs for purposes of the regression calculation), would be 
referred to as the CJR HCC count risk adjustment factor and the age 
bracket risk adjustment factor. Because the coefficients are calculated 
at the national level, the average risk score in a given region and MS-
DRG category may not be equal to one. As a result, the target price for 
a beneficiary could have a positive or negative risk adjustment applied 
even if that beneficiary's risk score is equal to the average risk of 
the regional population on which their target price was based. We 
considered alternative approaches of calculating coefficients 
separately for each region or applying risk-standardization to the 
regional target price prior to applying the beneficiary-specific risk 
score. However, we did not pursue these alternatives in an effort to 
minimize complication. We solicited comment on whether additional 
calculations steps should be included in order to ensure that the 
average risk score in a given region and MS-DRG category is equal to 
one.
---------------------------------------------------------------------------

    \8\ We requested comment on specification checks that should be 
conducted and on revisions, such as a switch to a fixed effects 
model, that would facilitate such additional analysis.
    \9\ We requested comment on the impact of this practice on the 
statistical validity of the model.
---------------------------------------------------------------------------

    An example of the regression output from this model is provided in 
Table 3. The output provided in Table 3 was calculated using the ``2018 
HCC payment year file'' data, which is derived from national episode 
claims data dated January 1, 2017 to December 31, 2017 for MS-DRG 469, 
MS-DRG 470, and the permitted outpatient TKA/THA CPT code. The ``Pr > 
t'' column indicates the probability value, or p-
value, that the effect of the risk adjustment factor is explained by 
that risk adjustment factor alone. Small p-values, typically less than 
0.05, indicate strong evidence that the effect can be attributed to the 
risk adjustment factor. As described later in this section, the high p-
value for the Dual Eligibility factor influenced our decision to not 
choose that risk adjustment factor. Indicated by the ``e\x\'' column, 
the risk adjustment coefficients represent the anticipated marginal 
cost associated with each specific risk adjustment factor. For example, 
the 1.116 value in Table 3 for beneficiaries Age 85+ indicates that 
beneficiaries 85 years and older are anticipated to increase marginal 
episode costs by 11.6 percent. These coefficients would be posted on 
the CMS website prior to each PYs 6 through 8, along with the average 
regional target prices, as described in section II.B.2 of this final 
rule.

[[Page 23526]]

[GRAPHIC] [TIFF OMITTED] TR03MY21.004

    An updated example of the regression output from this model is 
provided in Table 3a, which was calculated using national episode data 
from January 1, 2018 to December 31, 2018 (prior to the introduction of 
MS-DRGs 521 and 522), for MS-DRG 469, MS-DRG 470, and the permitted 
outpatient TKA/THA CPT code. When CMS updated the data in Table 3, we 
also discovered an error in the original programming regarding the 
definition of a dual-eligible beneficiary for the regression that 
inadvertently included beneficiaries enrolled in Medicare Part A and/or 
Part B and receiving full or partial Medicaid benefits. As noted in 
section II.C.4 of the proposed rule, our intention was to only include 
beneficiaries receiving full Medicaid benefits and not those only 
receiving partial Medicaid benefits. The correction in the programming 
to only include beneficiaries fully eligible for Medicaid benefits, as 
well as enrolled in Medicare Part A and/or Part B, demonstrates that 
there is strong evidence to suggest that the correctly defined dual 
eligibility status variable alone has a statistically significant 
effect on episode costs. Specifically, CMS observed a p-value of 
<0.0001 for the correctly defined variable using the 2017 claims data 
that was used for Table 3 in the proposed rule, as well as using the 
2018 claims data used to calculate the results in Table 3a in this 
final rule.

[[Page 23527]]

[GRAPHIC] [TIFF OMITTED] TR03MY21.005

    We proposed to conduct this linear regression model on updated 
baseline data and post the coefficients on the CMS website prior to the 
start of each of the performance years (6 through 8). By re-running the 
linear regression model each year based on more recent, nationwide data 
(including both CJR model and non-CJR episodes), we will more 
accurately account for changes in spending patterns that 
disproportionately impact certain subgroups within our two risk 
adjustment variables of CJR HCC count and age bracket. For instance, if 
a new LEJR-related treatment were introduced during the baseline 
period, but it was only appropriate for use in patients under the age 
of 85, then the risk for increased episode costs relative to the 
regional mean episode cost associated with being in the age brackets 
for beneficiaries under age 85 would be impacted differently than the 
risk of being in the 85+ age bracket. By re-running the linear 
regression model each year and updating the risk adjustment 
coefficients, we would be able to more accurately risk adjust at the 
episode level for all categories of beneficiaries at reconciliation.
    At reconciliation, after actual performance year episode costs are 
capped at the proposed 99th percentile consistent with our proposal to 
update the methodology used in deriving the high episode spending cap 
amount, the transformed risk adjustment coefficients for the two 
variables from the log-linear regression would be applied to quality 
adjusted target prices based on the applicable episode region and MS-
DRG. However, since the age and the CJR HCC count variables are 
inherently included in the regional target price, as regions with a 
higher proportion of older beneficiaries or beneficiaries with higher 
CJR HCC counts tend to have higher average episode costs, we propose to 
apply a normalization factor to remove the overall impact of adjusting 
for age and CJR HCC counts on the national average target price. This 
normalization factor would be the national mean of the target price for 
all episode types divided by the national mean of the risk-adjusted 
target price. For example, if the average target price for all episodes 
(average of all 36 MS-DRG 469, MS-DRG 470, MS-DRG 521, and MS-DRG 522, 
applied to all episodes in a year) is $22,000 and the average of target 
prices for the same set of episodes once risk adjustments are applied 
is $23,158, then the normalization factor would be computed as 0.95 
($22,000 divided by $23,158). We would then apply the normalization 
factor to the previously calculated, beneficiary-level, risk adjusted 
target prices specific to each episode region and MS-DRG combination. 
These normalized target prices would then be further adjusted for 
market trends (as detailed at Sec.  510.301) and quality performance 
(as specified at Sec.  510.300), prior to being compared to the episode 
costs (after episode costs are reduced for high episode spending as 
specified at Sec.  510.300 and/or extreme and uncontrollable conditions 
under Sec.  510.305). We note in this final rule we are making a 
technical change to the description of this process at Sec.  
510.301(a)(5)(iv) to streamline the regulation text.
    For example, a 70-year-old beneficiary with a CJR HCC count of 4, 
not a dual-eligible status beneficiary, located in the West North 
Central Division, region 4, has an MS-DRG 470 episode during PY6. 
Assume that the total actual cost for this episode was $21,900, which 
for purposes of this example we will assume is under the high cost 
episode cap amount and thus no capping needs to be applied to the 
actual costs and that the beneficiary was treated at a CJR participant 
hospital with a composite quality score of `Good' with a 1.5 percent 
withhold.
    Assuming the target price for region 4 DRG 470 is $17,097 (reflects 
a 3 percent quality withhold), the normalization factor in effect for 
PY6 is 0.95, and the market trend factor is 1.023, the target price 
applied for reconciling this episode would be computed as follows:
    Step 1. Risk adjust the target -Assuming the value shown in TABLE 
4: RISK FACTOR MULTIPLIERS FOR THE CJR MODEL FOR ALL AGE BRACKET AND 
CJR HCC COUNT COMBINATIONS of this proposed rule are in effect for 
purposes of this example, locate the appropriate risk adjustment co-
efficient combination for a CJR HCC count of 4 and age of 70 which is 
listed as 1.3633 and multiply the target price of $17,097 by that 
value:

$17,097 * 1.3633 = $23,308.34


[[Page 23528]]


    Step 2. Normalize the risk adjusted target price by multiplying it 
by the normalization factor of 0.95:

$23,308.34 * .95 = $22,142.92

    Step 3. Apply the market trend factor:

$22,142.92 * 1.023 = $22,652.21

    Step 4. Adjust the price to reflect the hospital's composite 
quality score category of `Good' (1.5 percent withhold rather than 3 
percent) by restoring 3 percent and then adjusting to withhold 1.5 
percent:

$22,652.21 * 100/97 = $23,352.79
$23,352.79 * .985 = $23,002.50

    Once the applicable risk adjusted, normalized, trend adjusted and 
quality adjusted target price is computed, the actual episode costs of 
$21,900 would be compared to the target of $23,002.50 and this episode 
would therefore show a savings of $1,102.50. We previously considered 
making risk adjustments based on a participant hospital's average HCC 
score for patients with anchor hospitalizations (80 FR 73338). However, 
we did not propose this policy because the HCC score was developed for 
applications in generalized population health and might not be 
appropriate for use in predicting expenditures for specific clinical 
episodes over a shorter period of time. We proposed to use the CJR HCC 
count and age variables as risk adjustment factors, as we believe that 
these variables do improve the predictability to our target pricing, 
even though they are not as fully comprehensive as the HCC score 
variable. As noted in the ``e\x\'' column of Table 3, the risk 
adjustment coefficients vary across groups consistent with expected 
increases in severity, and the coefficients are monotonic with respect 
to expected severity (with the exception of the under 65 age group, 
which is expected to be relatively expensive due to the high volume of 
disabled beneficiaries in that age group). Additionally, we proposed to 
use CJR HCC count and age because based on internal regression analyses 
using the coefficients from Table 3, those factors contribute an 
additional 7.1 percent of statistically significant predictability to 
our target price calculation. This improved accuracy in target pricing 
is especially important since early evaluation results from the CJR 
model that indicate a higher proportion of episodes are exceeding the 
high-cost episode cap than initially anticipated. Using the values from 
Table 3, we constructed Table 4 to illustrate the risk factor 
permutations for each Age Bracket and CJR HCC count category. 
Additionally, in this final rule, we used the values from Table 3a to 
construct an updated version of Table 4, which is Table 4a in this 
final rule. Table 4a illustrates the risk factor permutations for each 
Age Bracket and CJR HCC count category, as well as the dual-eligibility 
status factor. For PYs 6, 7 and 8, we proposed to publish updated 
versions of Tables 3a and 4a on the CMS website prior to the beginning 
of each performance year based on the data from the applicable baseline 
calendar year in order to communicate the specific risk factors 
applicable in a given performance year.
[GRAPHIC] [TIFF OMITTED] TR03MY21.006


[[Page 23529]]


[GRAPHIC] [TIFF OMITTED] TR03MY21.007

    Our intent with the proposed risk adjustment methodology is to 
reduce the need for application of the high-cost episode cap by more 
accurately setting and adjusting target prices, although our proposed 
new methodology for deriving the high episode spending cap amount may 
also reduce instances when the cap applies. This approach is responsive 
to commenters in past CJR model proposed rules that indicated the 
accuracy of target prices benefits participants by increasing financial 
predictability of participation in the model.
    We also considered, as a risk adjustment variable, a beneficiary's 
dual-eligibility status in Medicare and Medicaid, or a variable to 
potentially control for social determinants of health and patient 
economic demographics. As noted in section II.C.4 of this final rule, 
CMS updated the data in Table 3 with calendar year 2018 claims data and 
the correct definition of a dual-eligible beneficiary, and Table 3a 
demonstrates that there is strong evidence to suggest that the dual 
eligibility status variable alone has a statistically significant 
effect on episode costs. Specifically, CMS observed a p-value of 
<0.0001 for the correctly defined dual-eligibility status variable 
using calendar year 2018 claims data. As previously noted, other 
variables considered but not chosen due to similar lack of additive 
predictive power were rural or urban designation of the participant 
hospital and ZIP Code level. While we did not propose to include dual-
eligibility status as a risk adjustment variable, we sought comment on 
the inclusion of this and other risk adjustment variables in the model 
to account for such patient characteristics. Additionally, we chose 
binary variables to represent the risk adjustment factors since it is a 
generally accepted common practice in similar regression analyses, and 
for simplicity purposes in our model. However, we sought comment on 
alternative methods for expressing these factors in our exponential 
risk adjustment model.
    The following is a summary of the comments received and our 
responses.
    Comment: Many commenters were in support of the proposed episode-
level risk adjustment. All commenters that commented about using age as 
a risk adjustment variable were in support of the proposal. While most 
commenters were in support of using CJR HCC count as a variable, some 
commenters recommended adjustments. In particular, commenters 
recommended adjusting the methodology to account for the severity, or 
weight, of certain HCC conditions instead of the count of conditions 
alone. In particular, a commenter requested that CMS consider the 
relative impact on the perioperative period of some of the 
cardiovascular/pulmonary codes versus more chronic diseases that might 
be impactful longitudinally but do not have as much effect in an acute 
intervention setting. A commenter expressed support for the proposed 
risk adjustment variables, but recommended CMS strengthen its approach 
to quality measurement given the movement to the outpatient setting for 
these procedures.
    Response: We appreciate that many commenters supported the proposed 
risk adjustment variables and methodology. When developing the proposed 
risk adjustment methodology for the 3-year extension of the CJR model, 
we did consider including specific adjustments for the weight and 
severity of certain HCC conditions. However, we encountered problems 
with insufficient claim volume for certain HCC conditions, and when 
they were included in the regression modeling, they did not contribute 
any material improvement in statistical predictability of the 
regression model compared to simply using HCC condition count alone. As 
noted in section II.C.4 of this final rule, simplicity has been an 
important consideration as we introduced the proposed risk adjustment 
methodology, and we determined HCC condition count would be a more 
transparent approach to risk adjustment than if we had included a more 
complex approach with specific HCC conditions included in the 
regression modeling. CMS appreciates the commenters' suggestion to 
consider the relative impact on the perioperative period of some of the 
cardiovascular/pulmonary HCC condition codes versus more chronic 
diseases. Similar to our decision to not include a site of setting risk 
adjustment variable, we chose to exclude specific adjustment for 
certain HCC conditions in the regression model to avoid

[[Page 23530]]

creating incentives that may motivate participant hospitals to focus on 
coding certain HCC conditions due to their exaggerated effect in the 
risk adjustment methodology compared to other HCC conditions. As noted 
in section II.F.2 of this final rule, we believe the proposed quality 
measures, in conjunction with the proposed risk adjustment methodology, 
will ensure our inclusion of outpatient procedures in the model does 
not negatively impact beneficiary quality of care or safety.
    Comment: Some commenters recommended calculating the coefficients 
at the regional level instead of the proposed national level, citing 
the need to capture unobserved socioeconomic characteristics or other 
factors that vary by region. Some commenters recommended the effect of 
the risk adjustment variables be limited so they could only increase 
target prices (that is, do not apply any coefficients lower than 1.0), 
stating the purpose of the risk adjustment multiplier is to reduce the 
need for a high episode cap due to it being raised to the 99th 
percentile of historical costs. A commenter recommended that CMS 
calculate risk adjustment variables in a single regression that 
includes the MS-DRG and the fracture status. A commenter stated that 
since target prices reflect regional baseline costs, CMS should 
consider normalizing based on regional case mix.
    Response: We appreciate the suggestions from commenters on the 
calculation of the risk adjustment coefficients. We did sample 
coefficients calculated at the regional level and observed similar 
average effects compared to our nationally calculated coefficients. In 
particular, we observed only a 0.1 percent difference in r-squared, or 
the goodness of fit measure that measures the strength of the 
relationship between the model and the dependent variable, between the 
two regression models. We anticipate the additional inclusion of dual-
eligibility status as a risk adjustment variable in this final rule 
will capture some of the unobserved socioeconomic characteristics that 
may vary by region. We are also choosing to calculate the risk 
adjustments at the national level to reduce the complexity of 
calculating and posting on the CMS website coefficients for each of the 
three risk adjustment variables for each of the 9 regions of the CJR 
model. While CMS maintains the purpose of the risk adjustment 
methodology, as well as other proposed changes to the CJR model payment 
methodology meant to reduce the need for the high episode spending cap, 
we also designed the risk adjustment methodology to accommodate our 
inclusion of the outpatient and inpatient episode target price. Since 
outpatient procedures may be less costly than inpatient procedures for 
patients that share similar characteristics, we determined it would be 
inappropriate to limit the effect of the risk adjustment methodology to 
only increase target prices. While CMS considered the approach of using 
a single regression that includes the variables that define the 36 MS-
DRG and regional combinations and used that regression to predict the 
mean episode cost, we believed it would be simpler and equally 
effective to utilize a risk adjustment process that supplemented the 
existing structure and did not change the existing use of the 36 target 
price groups by defining the dependent variable in the regression as 
costs not already captured by the 36 target price group means. Lastly, 
we agree that target prices reflect regional baseline costs, but 
disagree that after risk adjustment, they should be normalized by 
region. We believe it would be inappropriate because the resulting 
effect would be that the risk adjustment process would only account for 
differences in severity within and not across regions.
    Comment: Commenters were in support of adding dual-eligibility or a 
similar risk adjustment variable that would effectively capture some of 
the cost variation related to a patient's socioeconomic determinants or 
status. In particular, a commenter noted that this variable should be 
included because it is associated with the likelihood of readmissions 
for Medicare beneficiaries undergoing these procedures, as evidenced by 
its inclusion as a stratified risk adjustment variable in the Hospital 
Readmissions Reduction Program. A commenter stated they appreciated the 
comprehensive description of CMS' analysis in the proposed rule, 
including its finding regarding dual-eligible status, and recommended 
that CMS explore proxy measures of socioeconomic status if dual-
eligibility is found to not be a significant predictor in the model.
    Response: We originally included the dual-eligibility status 
variable in our risk adjustment regression in an attempt to include an 
adjustment for a variable to potentially control for social 
determinants of health and patient economic demographics. We ultimately 
chose not to propose inclusion of this variable due to a p-value 0.4748 
that was calculated using 2018 claims data. However, as noted in 
section II.C.4. of this final rule, when CMS updated the data in Table 
3 with 2019 claims data we also discovered an error in the original 
programming regarding the definition of a dual-eligible beneficiary for 
the regression that inadvertently included beneficiaries enrolled in 
Medicare Part A and/or Part B and receiving full or partial Medicaid 
benefits. As noted in section II.C.4. of the proposed rule, our 
intention was to only include beneficiaries receiving full Medicaid 
benefits and not those receiving partial Medicaid benefits. The 
correction in the programming to only include beneficiaries fully 
eligible for Medicaid benefits, as well as enrolled in Medicare Part A 
and/or Part B demonstrates that there is strong evidence to suggest 
that the correctly defined dual-eligibility status variable alone has a 
statistically significant effect on episode costs. Specifically, CMS 
observed a p-value of <0.0001 for the correctly defined variable using 
the 2018 data that was used for Table 3 in the proposed rule, as well 
as using the 2019 data used to calculate the results in Table 3a in 
this final rule. As a result of this new evidence that suggests the 
dual-eligibility status variable alone does have a statistically 
significant effect on episode costs, and in response to comments, we 
are adding full dual-eligibility status as a risk adjustment variable 
to the CJR model in this final rule. Similar to the other risk 
adjustment variables, the dual-eligibility status variable will be a 
binary (yes or no) variable that indicates a beneficiary was enrolled 
in Medicare Part A and/or Part B and receiving full Medicaid benefits.
    Since we are finalizing an update to the target price methodology, 
as described in section II.B.3. of this final rule, such that target 
prices for PYs 6, 7, and 8 will be calculated with episode baseline 
data from 2019, 2021, and 2022, respectively, we are finalizing 
corresponding changes to the data used to calculate the risk adjustment 
coefficients. In particular, we are finalizing that the coefficients 
for each of the three risk adjustment variables will be calculated from 
Medicare claims data dated January 1, 2019 to December 31, 2019 for PY6 
and PY7, and from January 1, 2021 to December 31, 2021 for PY8. As 
noted previously, we agree with commenters that use of 2020 data should 
be avoided. Therefore, similar to declining to rely on the 2020 claims 
data used to calculate target prices as a result of potential 
distorting effects on the data due to the COVID-19 PHE, we are also not 
using that year of data for risk adjustment calculation purposes. In 
particular, we will hold the CJR HCC count risk adjustment factor 
coefficients

[[Page 23531]]

calculated with claims data dated January 1, 2019 to December 31, 2019 
for PY6 constant for PY7, since we are making corresponding changes to 
target price calculations to avoid using 2020 baseline data for target 
prices. Risk adjustment coefficients would then be updated and posted 
on the CMS website before PY8 begins, using claims data dated January 
1, 2021 to December 31, 2021. As noted in section II.B.3 of this final 
rule, we anticipate the corrective mechanisms of the PY6 methodology 
will reduce the distortion potentially caused by the COVID-19 PHE in 
the 2021 data. As 2021 data become available, we will monitor the 
potential effects of the COVID-19 PHE on that data and determine if any 
adjustment is needed regarding use of the 2021 data for PY8 risk 
adjustment coefficient calculations. All three risk adjustment factor 
coefficients will be posted on the CMS website prior to the start of 
each performance year, along with the applicable target prices. We 
appreciate that commenters were generally in favor of adding this dual-
eligibility status, or another variable, to capture the effect of a 
beneficiary's socioeconomic status on their episode costs.
    Comment: Some commenters were in support of adding other risk 
adjustment variables, including functional status, disability status, 
joint location, reason for Medicare eligibility, post-discharge 
destination, urban/rural patient address, patient demographics, 
sociodemographic status, marital status, race, ethnicity, income, and 
education.
    Response: CMS appreciates the additional risk adjustment variables 
that commenters suggested. We anticipate our addition of the dual-
eligibility status variable in this final rule may satisfy some of the 
recommendations from commenters to consider an additional risk 
adjustment variable that would adjust target price costs based on a 
patient's demographics, socioeconomic status, and other similar 
factors. As noted in section II.C.4 of this final rule, we designed the 
risk adjustment methodology to serve as a progressive step from the 
original CJR model methodology that adjusted MS-DRG 469 and 470 target 
prices based on fracture status alone. However, we must balance our 
objective to test innovative risk adjustment methodologies with the 
mandatory nature of the CJR model. We anticipate that some of the 
hospital participants that are selected for participation in the CJR 
model are not those that would have otherwise voluntarily chosen to 
participate in an APM and may not be as familiar with the related 
alternative forms of payment, such as the proposed risk adjustment 
methodology, so we intended to reduce complexity of the risk adjustment 
methodology by only selecting the most important risk adjustment 
variables. CMS also was limited in our ability to consider some risk 
adjustment factors, such as a patient's income or education, given the 
difficulty in consistently and accurately capturing this data and using 
it for risk adjustment purposes. As a result, we chose to limit the 
complexity of the risk adjustment methodology and are not including 
other factors at this time.
    Comment: Some commenters requested additional information about the 
process of calculating the episode-specific adjustments, with a 
commenter suggesting that CMS validate both exponential and linear risk 
adjustment regression models with 2019 data to evaluate goodness of 
fit. A commenter requested information on the factors that CMS chose 
not to include, specifically whether the mix of inpatient versus 
outpatient episode was a rejected factor. A commenter asked whether a 
sub-group analysis was done for the higher quintile cost groupings of 
the proposed risk adjustment variables to see if the effects of those 
risks become more apparent for poor urban populations, especially for 
the more specific grouping of very high cost outliers, stating that 
this this would also impact the proposed elimination of the outlier 
caps.
    Response: As described in section II.C.4 of this final rule, CMS 
tested the proposed risk adjustment regression model using 2019 
Medicare claims data. We determined that in addition to the risk 
adjustment variables originally proposed (age and CJR HCC count), the 
dual-eligibility status variable was also statistically significant, 
which led us to include that variable in the risk adjustment 
methodology described in this final rule. While we considered a linear 
regression model, we chose the exponential model because it yielded 
factors that can be applied directly to (that is, multiplied times) the 
existing target prices as proportional adjustments. The exponential 
model also yielded plausible statistically significant estimates of the 
effects for the proposed variables and added explanatory power. CMS did 
consider whether to include site of setting as a risk adjustment 
variable in the regression modeling. However, given the significant 
effect this variable would have on target prices (as a result of the 
variation in outpatient and inpatient episode costs), we did not 
propose to include it as a risk adjustment variable. We continue to 
assert that the risk adjustment methodology, with the addition of dual-
eligibility status as a variable, that we are adopting in this final 
rule will effectively capture the associated costs with CJR 
beneficiaries in either setting and will not infringe on the patient-
doctor decision-making. Regarding the comment that suggested CMS 
conduct a sub-group analysis for the higher quintile cost groupings of 
the proposed risk adjustment variables to see if the effects of those 
risks become more apparent for poor or urban populations, we anticipate 
the addition of the dual-eligibility status variable should help 
address this potential differential in effect size given the income 
limitations associated with beneficiaries enrolled in Medicaid
    Comment: Other commenters requested clarification on the timeframe 
that would be used to count the number of HCCs a beneficiary has, which 
should give providers a better understanding of the methodology and its 
effects. A commenter asked whether the HCCs will be captured through 
outpatient ICD-10 codes as well as inpatient, and for what preceding 
period.
    Response: We noted in the proposed rule that we would utilize 
beneficiary CMS-HCC condition count and age data from a baseline of 
January 1, 2019 to December 31, 2019 to calculate coefficients for both 
risk adjustment variables for PY6, data from January 1, 2020 to 
December 31, 2020 for PY7, and data from January 1, 2021 to December 
31, 2021 for PY8. As described in section II.B.3. of this final rule, 
while the same date ranges for data will be used to calculate the CJR 
HCC count, age, and dual-eligibility status risk adjustment variables, 
we will calculate coefficients for PY6 and PY7 using claims data dated 
January 1, 2019 to December 31, 2019, and coefficients for PY8 using 
claims data dated January 1, 2021 to December 31, 2021. Specifically, 
we will hold constant for PY7 the risk adjustment coefficients we 
calculate for PY6. We will post the applicable risk adjustment 
coefficients on the CMS website prior to the start of each performance 
year, along with the target prices applicable to that subsequent 
performance year. We believe that in general, holding constant the risk 
adjustment coefficients that are posted on the CMS website prior to the 
start of a performance year until they are used at reconciliation will 
be responsive to commenters that expressed concern about the proposed 
retrospective market trend factor of the proposed payment methodology. 
We also clarify that this HCC data will be captured for beneficiaries 
receiving both inpatient and outpatient procedures.

[[Page 23532]]

    Comment: A commenter recommended that since there is variability in 
the content of patients' medical records which may result in a hospital 
not capturing all of the patient's conditions, CMS should provide 
education to providers participating in the model and practitioners to 
better ensure they are aware of this change once finalized. A commenter 
requested that CMS provide HCC data in the current model year before 
finalizing the proposed rule, to allow participants to fully understand 
the implications of the proposed risk adjustment methodology.
    Response: We appreciate the recommendation that given the 
variability in the content of patients' medical records and its 
potential effect of not capturing all of a patient's conditions, CMS 
should provide education to providers participating in the model and 
practitioners. We will ensure this is appropriately provided in CJR 
model educational material and communications. Given the timing of this 
final rule and the PY5 operations currently underway in the CJR model, 
we are unable to retroactively provide current CJR participant 
hospitals HCC data. However, we are aware that the HCC data and the 
proposed risk adjustment methodology as a whole will be new to CJR 
participant hospitals in PY6, we plan to ensure these topics are 
effectively communicated to participants prior to the start of PY6 
through webinars, communications, and other learning material.
    Comment: Some commenters expressed concern at the timing of 
baseline data used to calculate the coefficients, noting that 
adjustments will be needed for PY7 given that COVID-19 will result in 
2020 volume of elective hip and knee surgeries that does not reflect 
the typical spending pattern of a hospital or region. A commenter 
suggested CMS consider how COVID-19 may necessitate a new HCC condition 
that could alter the proposed risk adjustment methodology.
    Response: As noted in section II.C.4 of this final rule, we are 
committed to testing the proposed risk adjustment methodology for the 
proposed 3-year extension of the CJR model. However, we also understand 
that due to the COVID-19 PHE, baseline data from 2020 will likely not 
be as reflective of true market conditions for PY7. As noted in section 
II.B.3 of this final rule, as a result of potential data issues due to 
the COVID-19 PHE, we are finalizing that PY6 target prices will be 
based on episode baseline data from calendar year 2019, but PY7 target 
prices will be based on episode baseline data from calendar year 2021, 
and PY 8 target prices on episode baseline data from calendar year 
2022. Similarly, we are finalizing corresponding changes to the timing 
of risk adjustment data to avoid the potential in distorting effects of 
the COVID-19 PHE on the 2020 data. In particular, PY6 and PY7 risk 
adjustment coefficients will be calculated based on claims data from 
January 1, 2019 to December 31, 2019, and PY8 risk adjustment 
coefficients will be calculated based on claims data from January 1, 
2021 to December 31, 2021. We will monitor the need for future 
adjustments to 2021 risk adjustment data as well.
    Comment: A commenter stated that CMS proposed to create an episode-
specific adjustment for each target price to account for a participant 
hospital's varying case mix and requested that CMS clarifies how it 
will calculate the proposed episode-specific adjustment.
    Response: While CMS proposed episode-level risk adjustment to 
account for the age and number of HCC conditions a certain beneficiary 
may have, we did not propose a general case-mix adjustment, such as a 
hospital's case mix indexes (CMI) for discharges which would be the sum 
of the average DRG relative weight of a hospital's discharges (as 
described on the CMS website: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS/Acute-Inpatient-Files-for-Download-Items/CMS022630).
    Comment: A few commenters expressed concern about applying the 
proposed risk adjustment methodology to both inpatient and outpatient 
episodes, stating that the relationship between excess costs and HCC 
condition count varies significantly between episodes that originate in 
the inpatient versus outpatient setting, and additional risk adjustment 
must be incorporated. Similarly, a commenter stated that the proposed 
risk adjustment methodology will not account for beneficiary-specific 
factors in situations where the same patient can have an elective 
procedure done in either inpatient or outpatient setting.
    Response: We anticipate that since the CJR HCC count risk 
adjustment factor will be calculated from annual HCC data, and not the 
HCC data documented on claims specifically related to a procedure, any 
variation in costs between episodes that originate in the inpatient 
versus outpatient setting is warranted and will appropriately account 
for the characteristics of those beneficiaries that are associated on 
average with more or less costs. CMS is not indicating that the 
proposed risk adjustment factors will capture patient preferences, or 
other beneficiary-specific factors, in situations where the same 
patient can appropriately have an elective procedure in either the 
inpatient or outpatient setting. We proposed the risk adjustment 
factors because we believe they will appropriately account for some of 
the episode cost differences related to those factors. We maintain that 
the decision for site of setting is a collaborative choice made by 
clinicians and patients and intentionally avoided using risk adjustment 
factors that could affect the nature of that decision.
    Comment: A few commenters suggested that CMS use the same risk 
adjustment model that is currently used in the BPCI Advanced model, and 
a commenter suggested that CMS adopt the Alternative Payment Condition 
Count (Alternative PCC) model since it includes new HCCs for Dementia 
and Pressure Ulcers. Similarly, a commenter suggested that CMS consider 
the benefit of aligning risk adjustment across models where it makes 
sense, using the most appropriate factors including an ability to adapt 
for changes in condition instead of relying too heavily on past 
behavior as the key predictor of the future, particularly to account 
for changing clinical practice patterns, and accounting for the number 
of chronic conditions of an individual.
    Response: We recognize the benefit of payment policy alignment 
across models, including the BPCI Advanced. Given the unique mandatory 
nature of participation in the CJR model, however, CMS strives to 
ensure transparency in the model's payment methodology. We must assume 
that some of the participants that were selected for participation in 
the CJR model are not those that would have otherwise voluntarily 
chosen to participate in an APM and may not be as familiar with the 
related alternative forms of payment, such as the bundled payments in 
the CJR model. As a result, simplicity has been a tenet of the CJR 
model's payment methodology, which led us to propose the age and CJR 
HCC count risk adjustment methodology for the proposed 3 additional 
years of the model. As CMS analyzes the results of more complicated 
risk adjustment methodologies, such as those in BPCI Advanced or those 
referenced by the commenter that would use the most appropriate factors 
(for example, including an ability to adapt for changes in condition), 
we will consider their effectiveness and appropriateness for adoption 
in other potential mandatory models. As described in section II.C.4 of 
this final rule, CMS selected the CJR

[[Page 23533]]

HCC count variable given the recent recognition and adoption of the HCC 
condition count variable described in section 17006(f) of the 21st 
Century Cures Act, which is similar to the HCC condition count variable 
in the Alternative PCC model. We consider this variable a potentially 
effective and simple risk adjustment variable that would be appropriate 
for the CJR model, but we do not believe the entire Alternative PCC 
model would be appropriate for the CJR model since it is meant to more 
comprehensively assess this risk of an entire patient population for 
Medicare Advantage, unlike the episode-level risk adjustment proposed 
for the 3 additional years of the CJR model.
    Comment: A commenter stated that insufficient information was 
provided to reach a conclusion on whether the risk adjustment method is 
appropriate. Another commenter responded to our request for comment on 
specification checks that should be conducted for the risk adjustment 
calculation and on revisions, such as a switch to a fixed effects model 
that would facilitate such additional analysis and stated the provider 
community lacks the necessary information to meaningfully comment on 
such a change and that if CMS would like substantive comments on a 
model that is different than the model proposed, CMS should provide the 
details of such a model.
    Response: We note and are concerned that the commenter believes 
insufficient information was provided to reach a conclusion on the 
appropriateness of the proposed risk adjustment method. We strived to 
notify the public of the proposed risk adjustment method in the most 
comprehensive manner, while balancing the burdens associated with 
regulatory review. As described in section II.C. of this final rule, we 
will post documentation about the applicable target prices and risk 
adjustment coefficients on the CMS website prior to the start of each 
performance year. As is standard CJR model policy, we will also answer 
any participant hospital questions regarding the risk adjustment 
methodology at the CJR mailbox: [email protected]. We believe the 
level of detail we provided in the proposed rule was sufficient for the 
provider community to comment on, as evidenced by the fact that the 
vast majority of commenters on this topic provided substantive 
comments, and only one commenter expressed concern, which indicates 
that commenters had enough information to meaningfully comment. When 
considering the additional risk adjustment for the 3-year extension of 
the model, we considered various statistical models, including a fixed 
effects model, to determine the effect of the risk adjustment variables 
and described these considerations and our decision making process in 
section II.C.4. of the proposed rule. Since this is a new risk 
adjustment method for the CJR model, we also sought comment broadly on 
whether a fixed effects, or any other statistical model, would be 
advantageous and whether CMS should consider alternatives. While we did 
not receive specific comments recommending other statistical models to 
consider, if CMS determines that an alternative statistical model could 
be more appropriate, we will address the details of such a model in 
future rulemaking.
    Final Decision: After consideration of comments received, we are 
finalizing the proposed risk adjustment methodology policy, with the 
following adjustments. We will add dual-eligibility status as a risk 
adjustment factor (defined as beneficiaries enrolled in Medicare Part A 
and/or Part B and receiving full Medicaid benefits on the first day of 
the CJR model episode) along with the existing factors of a 
beneficiary's age and CJR HCC count, as described at Sec.  
510.301(a)(1). We also note a numbering change to Sec.  
510.301(a)(1)(ii) in this final rule to ensure clarity regarding the 
age bracket variables. Additionally, the data used to calculate all 
risk adjustment coefficients for PY6 will be derived from Medicare 
claims data from January 1, 2019 to December 31, 2019; these 
coefficients will be held constant and used for PY7. The coefficients 
for PY8 will be derived from Medicare claims data from January 1, 2021 
to December 31, 2021.
5. Changes to Methodology for Determining the High Episode Spending Cap 
Amount at Reconciliation
    As discussed in section II.B.5. of this final rule, the high 
episode spending cap amount was designed to prevent providers from 
being held responsible for catastrophic spending amounts that they 
could not reasonably have been expected to prevent, such as post-acute 
care, related hospital readmissions, and other items and services 
related to the LEJR episode, by capping costs for those episodes at 2 
standard deviations above the regional mean episode price in 
calculating the target price and in comparing actual episode payments 
during the performance year to the target prices. However, the current 
methodology for setting the high episode spending cap amount has not 
been as successful when applied to actual performance period episode 
spending at reconciliation, illustrated by the fact that we have 
observed a high percentage of episodes exceed the cap during 
reconciliation, which indicates that the cap may not reflect true 
outlier costs. This may be partly explained by the fact that the TKA 
and THA procedure episode costs are not distributed normally. As 
discussed in section II.B.5 of this final rule, many LEJR episodes fall 
above 2 standard deviations from the mean at reconciliation (a much 
greater deviation than would occur if the costs were distributed 
normally). As a result, for PYs 6 through 8, we proposed to change our 
method of calculating the high episode spending cap amount applied 
during reconciliation by calculating high episode spending cap amounts 
based on the 99th percentile of costs. Similar to the current 
methodology, the high episode spending cap amounts applied during 
reconciliation for each MS-DRG would be derived from performance year 
regional spending. Total episode costs above the 99th percentile would 
be capped at the 99th percentile amount, and these capped episode 
amounts would be used when comparing performance year costs to target 
prices during reconciliation. We expect that this method of calculation 
will result in high episode spending cap amounts that more accurately 
represent the cost of infrequent and potentially non-preventable 
complications for each category of episode, which the participant 
hospital could not have reasonably controlled and for which we do not 
want to penalize the participant hospital. We proposed conforming 
changes to Sec.  510.200. The following is a summary of the comments 
received and our responses.
    Comment: Many commenters stated that the proposed cap is similar to 
spending cap policies for other CMS payment models and were supportive 
of consistency across CMS models wherever feasible. A few commenters 
recommended that if CMS finalizes the proposed high cost episode 
spending cap at the 99th percentile, then CMS should adjust the stop-
loss and stop-gain limit amounts to be 10 percent to account for these 
higher expenditures being included.
    Response: We appreciate that stakeholders recognize the potential 
benefit of aligning policies across models and the CJR model's 
intention to align where possible and appropriate. Given the similarity 
in the CJR model and the BPCI Advanced model, it makes sense to align 
the high episode spending cap for proposed PYs 6 through 8 with BPCI 
Advanced's existing policies and

[[Page 23534]]

maintain the 20 percent stop-gain and stop-loss limits.
    Comment: Some commenters opposed the proposed methodology for 
determining the high cost episode spending cap amount at 
reconciliation. A commenter stated that for a subset of elective LEJR 
patients, despite optimal care being provided prior to surgery, 
unexpected and severe complications do occur, and the proposed cap at 
the 99th percentile does not appropriately protect hospitals from 
incurring undue penalties because of these complications. Some 
commenters suggested we continue to use the current 2 standard 
deviation spending cap for high cost episodes, and other commenters 
recommended setting the cap at the 98th, 95th, 90th, or 80th 
percentiles. A commenter stated that the proposed high episode spending 
cap is arbitrary and there is no clear rationale for decreasing the 
number of episodes that can be capped to 1 percent.
    Response: We maintain that the risk adjustment methodology 
described in this final rule, with the addition of the dual-eligibility 
status variable, will effectively adjust target prices to account for 
characteristics of certain LEJR patients that are associated with 
higher costs. As we state in section II.C.5. of this final rule, we 
anticipate the other changes to the target price methodology we are 
adopting for PYs 6 through 8 also will limit the occurrence and need 
for the high episode spending cap used at reconciliation compared to 
the payment methodology for PYs 1 through 5. In particular, the policy 
to cap high cost episodes at the 99th percentile during reconciliation 
is consistent with, and mirrors the policy we are adopting in section 
II.B.5 of this final rule to calculate CJR model target prices during 
PYs 6 through 8 by capping high cost episodes in the baseline data at 
the 99th percentile. The alignment of these high cost episode caps is 
necessary to ensure they are symmetrically applied to episode costs 
during the target price calculation and reconciliation for each 
performance year. This is consistent with the high episode spending cap 
used in BPCI Advanced model. We analyzed internally the effect of 
adopting a high episode spending cap at the 98th percentile using the 
same 2018 claims data used to calculate the risk factor multipliers in 
Table 4 of this final rule. We observed that even at the 98th 
percentile, the high episode spending cap had the effect of capping 
more episodes than the previous method of capping episodes at 2 
standard deviations, which was contrary to our intention to change the 
high cost episode spending cap. As a result, we did not consider 
percentiles lower than 98th, such as 95th, 90th, or 80th as commenters 
suggest, and are adopting the 99th percentile in this final rule.
    Final Decision: After consideration of comments received, we are 
finalizing the proposed policy to change our method of calculating the 
high episode spending cap amount applied during reconciliation by 
calculating high episode spending cap amounts based on the 99th 
percentile of costs.
6. Changes to Trend Factor Calculation
    A limitation of the CJR model target price methodology for PYs 1 
through 5 is the absence of a trend factor calculation at 
reconciliation to incorporate and be responsive to ongoing practice 
changes in the joint replacement space. When we designed the original 
target price methodology, we did not anticipate the nationwide downward 
trend in use of post-acute care services. This decrease in use, 
corresponding to a decrease in average LEJR episode prices, was seen in 
both CJR model and non-CJR participant hospitals, representing an 
underlying trend in LEJR episode spending patterns that was neither 
specific to, nor driven by, CJR participant hospitals. This generalized 
downward trend was not incorporated into CJR model target prices, 
leading to artificially inflated target prices for CJR model episodes. 
Our goal is to reward CJR participant hospitals for decreased spending 
based on improved coordination and quality of care related to their 
participation in the CJR model, not to reward decreases in spending 
that likely would have occurred even in the absence of the model, as 
evidenced by comparably decreased spending in non-CJR participant 
hospitals. If the CJR model were to continue to provide artificially 
inflated target prices, the model would not decrease Medicare spending 
over time.
    Another major change that is not accounted for in CJR model target 
price methodology is the recent restructuring of the SNF payment system 
in the FY 2019 SNF PPS final rule (83 FR 39162). The original CJR model 
methodology assumed that the SNF payment system would retain the same 
structure, but would update prices on an annual basis, which would be 
reflected in the trend factor. However, effective October 1, 2018, we 
finalized a policy to change the case-mix methodology used to set 
payment rates for SNFs, which was implemented starting on October 1, 
2019 (83 FR 39162). The existing case-mix classification methodology, 
the Resource Utilization Group, Version IV (RUG-IV) model has been 
replaced by a new case-mix methodology called the PDPM. The new case 
mix methodology is designed to focus on the patient's condition and 
resulting needs for care, rather than on the amount of care provided, 
in order to determine Medicare payment. This structural change to the 
SNF payment system means that, if we were to try to adapt the existing 
CJR model trend factor methodology, prior year SNF spending can no 
longer be simply updated, but rather would need to be translated to 
reflect a different SNF payment methodology. A similar payment system 
change was finalized for the Home Health Prospective Payment System (HH 
PPS) in the CY 2019 HH PPS final rule (83 FR 56406) which updated the 
period of care and other methodological components of the HH PPS 
effective January 1, 2020. Similar to the FY 2019 SNF PPS updates, we 
anticipate the new strategy we proposed would account for these trends.
    The inability to integrate both generalized spending trends not 
driven by the CJR model, and major payment system changes, in 
combination with the fact that outpatient TKA data were not available 
prior to 2018, have led us to propose a new way to account for trend in 
CJR model target prices.
    Rather than the national update factor and biannual Medicare 
prospective payment and fee schedule update methodology we currently 
apply to historical episode spending in order to trend target prices 
forward prospectively (80 FR 73342), we proposed to calculate a market 
trend factor at the time of reconciliation by calculating the ratio of 
performance period spending to baseline period spending, and applying 
the resulting ratio to the target price.
    Specifically, after the beneficiary-level, risk adjusted target 
prices are normalized, as described in section II.B.5 of this final 
rule, the next step before reconciling expenditures would be to apply a 
market trend factor to the target prices. The market trend factor would 
be the regional/MS-DRG mean cost for episodes occurring during the 
performance year divided by the regional/MS-DRG mean cost for episodes 
occurring during the target price base year. For example, the PY6 
market trend factor for MS-DRG 470 in Region 1 would be calculated as 
the Region 1 mean episode costs for MS-DRG 470 episodes ending between 
January 1, 2021, to December 31, 2021, divided by the Region 1 mean 
episode costs for MS-DRG 470 without hip fracture episode ending 
between January 1, 2019, to December 31, 2019.

[[Page 23535]]

We note that after applying the adjustment to the IPPS payment for 
episodes with MS-DRGs 469 and 470 with fracture, they will be 
comparable to MS-DRGs 521 and 522 in the performance period, as 
described in section II.A.2. of this final rule, no further adjustment 
to the market trend will need to be performed. As a result, we would 
calculate 36 market trend factors during reconciliation, one for each 
MS-DRG and region combination. These market trend updates would then be 
applied to the normalized target prices discussed in section II.B.5 of 
this final rule. The resulting target prices would be the final target 
prices used when reconciling performance year episode costs. We 
proposed utilizing the regional mean episode costs as a basis for the 
market trend factor update calculation, but we sought comment on 
alternatively using the regional median episode costs for this 
calculation.
    Combined with our proposal to use 1 calendar year of baseline data 
to calculate CJR model target prices for PYs 6 through 8 (discussed in 
section II.B.3. of this final rule), the proposed changes to our trend 
factor calculation methodology will allow us to capture both trends in 
spending patterns and payment system updates in a simplified, 
retrospective manner. The following is a summary of the comments 
received and our responses.
    Comment: Some commenters generally agreed with the proposed market 
trend factor, with some agreeing in particular with the proposal to 
calculate the market trend factor at the regional level. MedPAC 
expressed support for the market trend factor only when it reduces 
target prices and recommended that in years when the market trend 
factor would increase the target price, CMS should not apply the market 
trend factor and instead only update target prices to reflect updates 
to Medicare payment systems and fee schedules (consistent with the 
model's current approach). Similarly, a commenter suggested that if CMS 
finalizes their proposed market trend factor they also implement a cap 
of 1 percent on changes in utilization-related pricing factors.
    Response: CMS appreciates the supportive comments received 
regarding the proposed market trend factor, in particular, our proposed 
method to calculate the factor at the regional level. Given the 
variable trends in the LEJR market, as discussed in section II.B. of 
this final rule, as well as the potential disruption created by the 
COVID-19 PHE, CMS determined it would not be appropriate to limit the 
effect of the market trend factor (for example, limited by decreases to 
target prices as suggested by MedPAC, or limited by decreases or 
increases of 1 percent as another commenter suggested). We believe that 
in conjunction with the other payment methodology policies in this 
final rule, such as the proposed use of a 99th percentile high cost 
episode cap for target price and reconciliation calculations and the 20 
percent stop-gain and stop-loss limits, it is not necessary to impose a 
cap or limit on the effect of the market trend factor and that doing so 
could actually be inappropriate if there are significant variations in 
market conditions in the baseline data period compared to each 
performance year.
    Comment: Many commenters were generally opposed to the proposed 
market trend factor, and some commenters suggested the existing twice 
annual update for payment system changes is sufficient. Many commenters 
stated the market trend factor is unnecessary and expressed concern 
that participants may have fewer opportunities to track and improve 
performance and that financial predictability may be lost if it is 
finalized. In particular, a few commenters noted that target price 
volatility resulting from the market trend factor would strain a 
hospital's relationship with the physicians with whom it has entered 
into gainsharing agreements to improve outcomes for Medicare 
beneficiaries.
    Response: As noted in the discussion before Table 6a of section 
IV.C. of this final rule, we anticipate the market trend factor will 
alleviate the need for the twice annual update for payment system 
changes and that it will actually capture these changes more accurately 
than the twice annual update methodology. In particular, the previous 
update methodology was prescriptive of which payment systems it would 
update target prices for, and it did not anticipate the addition of a 
new payment system (for example, the SNF PDPM) and was unable to adjust 
for this update. Since the market trend factor is rooted in episode 
costs and agnostic to a change in any one particular payment system, we 
believe it will more appropriately account for differences between 
baseline and performance period spending than the previous twice annual 
update. Additionally, while the market trend factor may have the effect 
of decreasing target prices as a result of lower performance period 
average costs compared to baseline costs, as we note in section II.C.6 
of this final rule, the market trend factor could also have the effect 
of increasing target prices to reflect higher performance period 
average costs. This could be particularly important if there is an 
innovative new device introduced for LEJR patients that increases 
average episode costs, or as a result of significant changes in patient 
case mix (for example, the potential impact of the COVID-19 PHE).
    CMS recognizes the retrospective nature of the market trend factor 
may create uncertainty for participant hospitals. However, we believe 
it is important to balance this uncertainty with the need to accurately 
account for changes in the market. As noted in section II.A.2 of this 
final rule, the LEJR market in particular is undergoing many changes 
with the movement to outpatient procedures in 2018 and 2020. We 
determined that the uncertainty of the retrospective trend adjustment 
is appropriate to ensure accurate target prices for both hospital 
participants and any physicians with whom they enter gainsharing 
agreements, and that it is a necessary and important component of the 
entire CJR model payment methodology adopted for PYs 6 through 8, 
especially given the use of 1 year of baseline data. In this final 
rule, we also attempted to increase target price predictability for 
participant hospitals by providing sample target prices in Table 2a and 
by clarifying that the CJR HCC count coefficients posted on the CMS 
website prior to the start of each performance year will not change or 
be updated at reconciliation.
    Comment: Some commenters stated the market trend factor would 
unfairly lead to decreased target prices for well-performing CJR model 
participant hospitals over time and would penalize the provider 
unnecessarily and obstruct their ability to continue delivering quality 
care at reduced costs. Some commenters stated that the proposed market 
trend factor is unnecessary for CMS to seek additional savings and is 
unfair given the increased administrative and financial burden it 
places on participants.
    Response: Many of the CJR model payment methodology changes CMS is 
adopting in this final rule for PYs 6 through 8 are interdependent, and 
we believe will only be successful if implemented together. For 
example, the addition of outpatient procedures to the episode 
definition, which will create site-neutral target prices that are 
adjusted based on patient characteristics (age, CJR HCC count, and 
dual-eligibility status), is only possible if the risk adjustment 
methodology described in section II.C.4. of this final rule is 
simultaneously implemented. If the risk adjustment methodology were not 
also implemented, the regionally calculated

[[Page 23536]]

site-neutral target prices could be inappropriately low for inpatient 
episodes at certain participant hospitals or inappropriately high for 
outpatient episodes at other participant hospitals based on the fact 
that the target prices will be calculated by blending the generally 
lower-cost outpatient episodes with generally higher-cost inpatient 
episodes. Similarly, we are only able to adopt the use of 1 year of 
baseline data for target price calculation purposes for PYs 6 through 8 
if we are also able to simultaneously adopt the market trend factor, 
which is meant to ensure consistency between baseline and performance 
period spending patterns. We recognize the use of 1 calendar year of 
baseline data compared to 3 years of data could create increased 
variation between performance period and baseline spending patterns and 
are adopting the market trend factor in response to this potential 
increase in variation. We are also adopting a simplified version of the 
CJR model payment methodology in this final rule by removing the twice 
annual update for payment system changes, and this would also not be 
possible without the market trend factor that is intended to accomplish 
the same effect of updating for payment system changes. In conjunction 
with these policies, we anticipate the proposed market trend factor 
will ensure consistent and more accurate pricing when comparing the 
baseline period to the performance year than the CJR model payment 
methodology used for PYs 1 through 5. CMS also asserts that our use of 
regional only data for target price calculations in PYs 6 through 8 
(instead of using hospital-specific data that could penalize a hospital 
for its own improvements and potentially limit the hospital's ability 
to achieve savings) will still create an opportunity for participants 
to utilize the CJR model flexibility (for example, gainsharing 
agreements), achieve lower average episode spending compared to their 
regional peers, and achieve savings in the CJR model during PYs 6 
through 8. We realize more accurate target prices could mean lower 
target prices (if average LEJR episode spending continues to decrease 
over time), but as noted previously and in section II.C.4. of this 
final rule, we also anticipate that the proposed risk adjustment 
methodology will appropriately adjust target prices based on certain 
beneficiary characteristics and that this risk adjustment methodology 
is an improvement from the previous methodology that simply adjusted 
target prices based on the presence of a hip fracture.
    Comment: A few commenters suggested calculating the market trend 
factor after excluding beneficiaries receiving an LEJR procedure from a 
participant in either the CJR model or BPCI Advanced, or after 
excluding beneficiaries aligned to a Medicare ACO. Some commenters 
opposed the proposed policy to calculate a blended target price with 
inpatient and outpatient episodes and recommended CMS create separate 
target prices. As a result of these changes, the commenters noted that 
the market trend factor would similarly need to be calculated 
separately for inpatient and outpatient episodes. Similarly, some 
commenters noted that the market trend factor methodology is a 
disincentive for use in the inpatient setting. Specifically, the 
commenters state that because CMS proposes to maintain the 100 percent 
regional pricing methodology, the proposed market trend factor would 
set target prices based on the regional rate of outpatient procedures, 
which has the potential to create a race to the bottom and unfairly 
penalize providers treating a higher proportion of complex patients.
    Response: Similar to our policy to include CJR model, BPCI 
Advanced, and Medicare ACO beneficiaries in the baseline data to more 
accurately reflect national average spending patterns, we determined 
that it would be appropriate to also include these beneficiaries in the 
market trend factor calculation. As noted in section II.C.2. of this 
final rule, when CMS proposed the blended target price, we also 
proposed the risk adjustment factors to account for the potentially 
higher costs associated with certain patients that would likely be more 
appropriate for the inpatient versus outpatient setting. We continue to 
believe the risk adjustment methodology will accomplish this, and we 
also believe the model's quality measures, noted in section II.F. of 
this final rule, and other CMS penalties associated with patient 
complications will effectively guard against inappropriate outpatient 
utilization. CMS recognizes that incorporating outpatient procedures 
into the target price methodology, with 100 percent regional data used 
for target price calculations, would in general have the effect of 
decreasing target prices, as is evidenced in the sample target prices 
in Table 2a of this final rule. However, we do not believe this will 
constantly decrease target prices, or create a race to the bottom, or 
unfairly penalize providers treating a higher proportion of complex 
patients because the effect of the risk adjustment will be to increase 
target prices for episodes for such beneficiaries. In particular, as 
noted in Table 4a of this final rule, the risk adjustment factors could 
have the effect of increasing target prices up to 250 percent for a 
beneficiary that is dual-eligible, 85 years or older, and with four or 
more HCC conditions.
    Comment: A commenter noted that since episode costs are not 
normally distributed, the median cost is more appropriate than the mean 
to calculate the market trend factor since it is a non-parametric (not 
normally distributed, or asymmetrical) measure of central tendency.
    Response: CMS recognizes that since episode costs are not normally 
distributed, the median could be considered a more appropriate variable 
to calculate the market trend factor compared to the mean. We completed 
internal analysis of the potential effect of using the median to 
calculate the market trend factor and observed a nominal difference 
compared to using the mean of episode costs. In particular, the trend 
factors calculated using means were 0.01 higher than trend factors 
calculated using medians. The differences in trend factors by region 
and MS-DRG ranged between -0.03 and 0.10. This effect is not 
surprising, as the distribution of standardized CJR model episode costs 
is right-skewed, meaning it is not normally distributed and more 
episodes have average costs that are above the median. Given the 
relative small difference in effect, and the benefit that using the 
mean of episode costs could have for participant hospitals (that is, 
increasing target prices more compared to the median), we continue to 
believe the mean of episode costs is more appropriate for calculating 
the market trend factors.
    Comment: A commenter agreed with the theory of a trend factor but 
suggested the CJR model adopt a prospective trend factor, similar to 
BPCI Advanced. Similarly, another commenter urged CMS to consider 
methodologies to incorporate trend factors directly into the target 
price on a prospective basis while retaining reasonable savings 
potential for both CMS and model participants. A commenter suggested 
that a baseline combination of historical data and regional pricing 
would create a more reasonable trend adjustment that does not unfairly 
penalize hospitals for performing well in the model. A commenter 
requested that CMS recognize in the calculation of the regional trend 
factor an amount to reflect the contribution of CJR model incentives to 
reduce spending for post-

[[Page 23537]]

acute care above the secular trend in FFS spending.
    Response: CMS understands the request of participant hospitals to 
incorporate a prospective market trend factor in the CJR model, similar 
to BPCI Advanced. As noted in section II.A.2. of this final rule, the 
LEJR market is currently evolving with TKA and THA shifting to the 
outpatient and ASC setting. The unknown effect of this migration, 
compounded by the potential effects of the COVID-19 PHE, elevates the 
importance of a mechanism to retrospectively adjust target prices at 
reconciliation and we maintain the market trend factor must be applied 
retroactively to be effective in this regard. As we note in section 
II.B.3. of this final rule, we recognize 2020 calendar year claims data 
may not be reflective of PY7 market conditions as a result of the 
COVID-19 PHE and are modifying our target price calculation such that 
PY7 target prices will be calculated using 2021 calendar year claims 
data instead of the proposed 2020 calendar year claims data. While 2021 
data could also have distortions as a result of the COVID-19 PHE, we 
anticipate the corrective mechanisms of the PYs 6 through 8 payment 
methodology, in particular the market trend factor, will reduce this 
distortion. For this reason, we do not believe it is necessary to 
prospectively provide for a separate adjustment because we anticipate 
the market trend factor, as a result of its ability to retrospectively 
adjust target prices at reconciliation for variation that occurred 
between the baseline and performance period, will reduce the potential 
necessity to adjust 2021 data to account for the effect of the COVID-19 
PHE.
    We also note that the BPCI Advanced's prospective Peer Adjusted 
Trend (PAT) Factors approach is more complex than the market trend 
factor we are adopting in this final rule and relies on adjustments for 
peer group characteristics, time trends, and interactions (as described 
further on the CMS website here: https://innovation.cms.gov/files/x/bpciadvanced-targetprice-my3.pdf). Given the potential burden of 
implementing a more complex approach for mandatory CJR model 
participant hospitals that may not be familiar with intricate risk 
adjustment methods compared to voluntary participants in BPCI Advanced, 
as well as the administrative cost of calculating this factor each 
year, we do not believe it would be appropriate for use in the CJR 
model. Given the proposed use of regional only data in the target price 
calculations, we determined it would be inappropriate and inconsistent 
to include hospital-specific historical data in the market trend factor 
calculation since it could potentially penalize hospitals for their own 
improvement in historical episode costs. As noted in section II.B.3. of 
this final rule, we will not exclude beneficiaries from the baseline 
data used for target price calculations that were aligned under an APM, 
such as the CJR model, BPCI Advanced, or a Medicare ACO initiative, 
because we believe their inclusion is more reflective of the true 
average costs of care given the proliferation of APMs. Similarly, we do 
not believe it would be appropriate to include adjustments in the 
market trend factor to account for the effect of CJR model incentives 
compared to FFS spending because we consider these effects and their 
impact on costs to be reflective of the true average costs of care. 
Lastly, we believe this adjustment could make the market trend factor 
overly complex and difficult to update for the potentially different 
effects of the payment methodology changes in this final rule compared 
to the CJR model payment methodology in PYs 1 through 5.
    Final Decision: After consideration of comments received, we are 
finalizing the proposed policy to include a market trend factor that 
will be the regional/MS-DRG mean cost for episodes occurring during the 
performance year divided by the regional/MS-DRG mean cost for episodes 
occurring during the target price base year.
7. Changes to Composite Quality Score Adjustment
    When setting an episode target price for a participant hospital, we 
currently apply a 3 percentage point discount to establish the episode 
target price that applies to the participant hospital's episodes during 
that performance year. We established this policy because we expect 
participant hospitals to have significant opportunity to improve the 
quality and efficiency of care furnished during episodes in comparison 
with historical practice, because this model facilitates the alignment 
of financial incentives among providers caring for beneficiaries 
throughout the episode. This discount serves as Medicare's portion of 
reduced expenditures from the episode, with any episode expenditure 
below the target price potentially available as reconciliation payments 
to the participant hospital where the anchor hospitalization occurred.
    For PYs 1 through 5, a 1 percentage point reduction is applied to 
the 3 percent discount factor for participant hospitals with good 
quality performance, defined as composite quality scores that are 
greater than or equal to 6.9 and less than or equal to 15.0. 
Additionally, for PYs 1 through 5, a 1.5 percentage point reduction is 
applied to the 3 percent discount factor for participant hospitals with 
excellent quality performance, defined as composite quality scores that 
are greater than 15.0.
    While we did not propose to change the 3 percentage point discount 
factor, we proposed to increase a participant hospital's ability to 
reduce the discount factor as a result of its composite quality score. 
We proposed this change in recognition that the proposed changes to the 
target price calculation (discussed in section II.B. of this final 
rule), intended to increase the accuracy of target prices compared to 
actual performance period spending may also narrow the potential for 
participant hospitals to earn reconciliation payments. For PYs 1 and 2, 
a large majority of CJR participant hospitals received a reconciliation 
payment: 44 percent of CJR participant hospitals received 
reconciliation payments in both performance years and an additional 33 
percent received a reconciliation payment in 1 of the 2 performance 
years; 23 percent never received reconciliation payments.
    Because of these more accurate target prices, and the fact that all 
participant hospitals would be at financial risk during PYs 6 through 
8, we determined that a more generous composite quality score 
adjustment to the discount factor is appropriate. The composite quality 
score adjustment for PYs 1 through 5, with a maximum potential for a 
1.5 percentage point reduction to the discount factor, could 
potentially force the target amounts calculated under the proposed 
methodology (discussed in section II.B. of this final rule) under an 
appropriate actual cost amount, which is not the intent of the model. 
While the discount factor was meant to serve as Medicare's portion of 
reduced expenditures from an episode, we determined that the proposed 
changes to the target price methodology are adequate to maintain an 
appropriate level of reduced expenditures for Medicare while rewarding 
participant hospitals with high composite quality score. For further 
information on the anticipated model savings as a result of the 
proposed target price changes, see section IV.C. of this final rule.
    As a result, we proposed that, for PY6 through 8, a 1.5 percentage 
point reduction be applied to the 3 percent discount factor for 
participant hospitals with good quality performance, defined as 
composite quality scores that are

[[Page 23538]]

greater than or equal to 6.9 and less than or equal to 15.0. 
Additionally, we proposed that a 3 percentage point reduction be 
applied to the 3 percent discount factor for participant hospitals with 
excellent quality performance, defined as composite quality scores that 
are greater than 15.0. That is, for participant hospitals with 
excellent quality performance, the 3 percentage point discount factor 
will effectively be eliminated for the applicable performance year.
    Comment: Several commenters support the proposal to increase the 
quality score adjustment to a 1.5 percentage point reduction to the 
applicable discount factor for participant hospitals with ``good'' 
quality performance and a 3 percentage point reduction to the 
applicable discount factor for participant hospitals with ``excellent'' 
quality performance.
    Response: We thank the commenters for their support on this topic.
    Comment: MedPAC suggested that CMS could take various steps to 
increase the likelihood of savings being generated, such as increasing 
the episode target price discount factor from 3 percent to 5 percent.
    Response: CMS appreciates MedPAC's suggestions to generate 
additional savings for the Medicare program by increasing the discount 
factor. Many of the changes CMS proposed to the CJR model payment 
methodology for PY6 through 8 are intended to be improvements to the 
original methodology that will increase the probability for model 
savings. While CMS could design a payment methodology that attributed a 
much larger portion of savings to the Medicare program through a higher 
discount factor, we must also balance the administrative burden and 
investments needed by participating hospitals to be successful under 
the model, and thus propose to maintain the 3 percent discount factor 
that is intended to ensure that CJR participant hospitals are still 
capable of achieving a certain level of savings for themselves in the 
model.
    Final Decision: After consideration of the public comments we 
received, we are finalizing the proposed change to percentage reduction 
to the discount factor for participant hospitals with good and 
excellent quality performance.

D. Three-Year Extension (PYs 6 Through 8)

1. PYs 6 to 8 Timeframe
    As noted in sections II.B. and II.C. of this final rule, we 
proposed changes to the CJR model target price methodology and the 
reconciliation process primarily to account for the removal of TKA and 
THA procedures from the IPO list and analysis of the reconciliation 
process for CJR model PYs 1 to 2 that indicates the process is not 
functioning as initially intended (for example, a larger number of 
episodes are being capped by the high episode spending cap amount than 
we anticipated). We proposed to extend the CJR model for an additional 
3 years to run through December 31, 2023, to allow sufficient time to 
evaluate the impact of the changes we proposed to resolve these 
concerns. We proposed that, while PY6 episodes would end on or after 
January 1, 2021, PY6 episodes would start as of the later of October 4, 
2020, or the date on which the final rule becomes effective. We 
solicited comment on our proposed start date of PY6, determining that 
this additional time is needed to complete the model test to generate 
the necessary evaluation findings for an expansion. Extending the model 
for 3 additional performance years will allow the Innovation Center to 
test and evaluate the model while promoting the alignment of quality 
with financial accountability. We proposed to change the regulations 
under 42 CFR part 510 to reflect this extension.
    Further, the November 2020 IFC extended PY5 an additional 6 months 
to end on September 30, 2021. As a result of this new PY5 end date, we 
sought comment in the November 2020 IFC on the duration of PY6 of the 
CJR model. In particular, we sought comment on the potential for PYs 6 
through 8 to remain 12 month performance years or for increasing the 
duration of PY 6 to 15 months.
    Comment: Many commenters noted concerns regarding the impact of the 
COVID-19 PHE on the performance period. Some commenters expressed 
concern that the public health emergency (PHE) impact may endure far 
beyond the proposed timeline and requested that the CJR model be 
terminated at the conclusion of PY5 without the proposed 3 year 
extension. Furthermore, due to the serious complications suffered by 
older adults and those with underlying health conditions, it was 
recommended that the U.S. health system limit non-emergency, elective 
services to help prevent further exposure of the virus and to preserve 
essential medical supplies. Some commenters requested that CMS hold 
hospitals harmless from penalties for the 2020 performance year due to 
their focus on defeating COVID-19. In addition, requests for 
adjustments to financial expenditures, performance scores and risk 
adjustment were made for PY5 and PY6 due to hospital resources being 
shifted to combat the virus. Many commenters also noted concerns 
regarding the impact of the COVID-19 PHE on participants' financial 
stability to maintain administrative, post-acute care and care 
management infrastructure absent the reconciliation payments that would 
be anticipated from participation in the CJR model.
    Response: We understand commenters' concerns regarding the effect 
of the COVID-19 PHE on CJR participant hospitals and the health care 
system as a whole. We do not believe terminating the model at the end 
of PY5 would be the appropriate response to dealing with the COVID-19 
PHE. As outlined in section II.K. of this final rule, we adopted 
policies in the April 2020 IFC and the November 2020 IFC to provide 
flexibilities for CJR participant hospitals during the PHE. In the 
April 2020 IFC, we originally extended PY5 to March 31, 2021 and we 
adjusted the extreme and uncontrollable circumstances policy to provide 
generous financial safeguards for CJR participant hospitals during the 
emergency period. In the November 2020 IFC, we adjusted the extreme and 
uncontrollable circumstances policy to provide a more targeted 
adjustment so that safeguards continue to apply for CJR episodes during 
which a CJR beneficiary receives a positive COVID-19 diagnosis. We also 
extended PY5 an additional six months to end on September 30, 2021.
    Comment: A commenter requested PY5 be extended until December 31, 
2021, such that PY7 and PY8 would start January 1, 2023 and January 1, 
2024, respectively, citing as a benefit alignment between performance 
and calendar years. Another commenter recommended keeping PYs 6 through 
8 as 12 months, but did not cite a specific reason.
    Response: CMS agrees with the commenter that cited a preference for 
alignment of calendar and performance years for PYs 6 through 8, as 
this adds operational simplicity to the model design and follows the 
same alignment of PYs 1 through 5 that is already familiar to 
participant hospitals.
    Comment: Commenters appreciated the continuous operation of the CJR 
model without interruption, but expressed concerns that the timeline 
proposed was unrealistic. Commenters stated that the ramp-up period 
required considerable re-tooling for the revisions proposed and 
recommended delaying the PY6 start date to at least six months after 
publication of the final rule or until the beginning of 2022.
    Response: We appreciate the views of our commenters in our efforts 
to uphold

[[Page 23539]]

continuity in the CJR model. We are adopting an episode definition 
change in order to address changes to the IPO list that now allow for 
TKA and THA to be treated in the hospital outpatient setting. In 
addition, this rule adopts changes to the CJR model target price 
methodology and reconciliation process. We believe that these changes 
will not require participants to rebuild operational processes because 
the fundamental characteristics of the model, a bundled payment for a 
90-day LEJR episode, have not changed. CMS will continue to provide the 
same support and resources to participant hospitals during the 
extension period as we did throughout the original performance period 
of the model.
    Comment: Several commenters supported the 3-year extension of the 
CJR model.
    Response: We appreciate the support given by the commenters in 
favor of the 3-year extension to the CJR model.
    Comment: Commenters encouraged CMS to maintain a seamless 
transition between model years, particularly between PY5 and PY6. Some 
commenters requested clarification on how the 3-month extension of PY5, 
to March 31, 2021 which was established in the April 2020 IFC, will 
impact the proposed rule.
    Response: We agree with the commenters that maintaining a seamless 
progression between PY5 and PY6 is critical. In the November 2020 IFC, 
CMS implemented an additional six-month extension to PY5 such that PY5 
will now end on September 30, 2021. PY6 will start at the conclusion of 
PY5 and will run until December 31, 2024, thus creating no gap between 
performance years and realizing full continuity in the model. The 
extension of PY5 impacts the October 4, 2020 date used as a deadline 
for rural reclassification status. The new date will be July 4, 2021 to 
accommodate the revised start date of PY6, which is October 1, 2021.
    Comment: A commenter requested clarification on what will happen at 
the conclusion of the 3-year extension, along with what changes will 
take effect. Another commenter suggested that CMS continue to support 
value-based payment models by creating a sustainable payment pathway 
for participants who are committed to moving away from FFS care.
    Response: We appreciate the comment and will continue to monitor 
and evaluate model performance through the 3-year extension. CMS is 
dedicated to testing alternatives to FFS care and improving value based 
payment models. Any potential future changes to the CJR model will be 
done via notice-and-comment rulemaking.
    Comment: A commenter suggested termination of the CJR model at the 
conclusion of PY5 and instead suggested developing a pathway for 
hospitals to become voluntary episode initiators for BPCI Advanced. 
Other commenters questioned the necessity of the 3-year extension 
stating that no new information would be gathered that has not already 
been realized during the model's five-year run.
    Response: We appreciate the comments. However, initial evaluation 
results \10\ for the first and second year of the CJR model indicate 
that the CJR model is having a positive impact on lowering episode 
costs while maintaining care quality. Despite these positive initial 
evaluation results, the changes we are making to the CJR model in this 
final rule will allow the CJR model to adapt to market conditions and 
provide additional time to assess these changes and evaluate their 
impact.
---------------------------------------------------------------------------

    \10\ Evaluation report located on the CJR Model website--https://innovation.cms.gov/innovation-models/cjr.
---------------------------------------------------------------------------

    Final Decision: As a result of the adjusted PY5 end date to 
September 30, 2021, and in consideration of the comments we received 
regarding this topic in the November 2020 IFC, as outlined in section 
II.K. of this final rule, we are finalizing in this final rule that PY6 
will be 15 months, such that it will begin with episodes ending on or 
after October 1, 2021 and end with episodes ending on or before 
December 31, 2022. We are also finalizing corresponding changes to the 
start and end dates for PYs 7 and 8. In particular, PY7 will begin with 
episodes ending on or after January 1, 2023 and end with episodes 
ending on or before December 31, 2023. Additionally, PY8 will begin 
with episodes ending on or after January 1, 2024 and end with episodes 
ending on or before December 31, 2024.
2. Participant Hospital Definition
    In the December 2017 final rule (82 FR 57074) CMS established that 
effective with PY 3 the MSAs in the CJR model were split into 34 
mandatory MSAs and 33 voluntary MSAs, and effective February 1, 2018 
model participation would not be required for rural and low-volume 
hospitals in mandatory MSAs or for all hospitals in voluntary MSAs. CMS 
provided rural and low-volume hospitals in mandatory MSAs and all 
hospitals in voluntary MSAs a one time opt-in to continue in the model 
for PY 3 to PY 5. We updated the definition of participant hospital in 
the December 2017 final rule, to reflect that beginning February 1, 
2018, a participant hospital (other than a hospital excepted under 
Sec.  510.100(b)) is one of the following: A hospital with a CMS 
Certification Number (CCN) primary address located in a mandatory MSA 
as of February 1, 2018 that is not a rural hospital or a low-volume 
hospital on that date; or a hospital that is a rural hospital or low-
volume hospital with a CCN primary address located in a mandatory MSA 
that makes an election to participate in the CJR model in accordance 
with Sec.  510.115; or a hospital with a CCN primary address located in 
a voluntary MSA that makes an election to participate in the CJR model 
in accordance with Sec.  510.115. The CJR model does not include 
geographically rural areas; however, some hospitals in the MSAs in the 
CJR model are considered to be rural for other reasons, such as 
reclassifying as rural under the Medicare wage index regulations. For 
purposes of the CJR model, a rural hospital means an IPPS hospital that 
is located in a rural area as defined under Sec.  412.64 of this 
chapter; is located in a rural census tract defined under Sec.  
412.103(a)(1) of this chapter; or has reclassified as a rural hospital 
under Sec.  412.103 of this chapter. Additionally, for purposes of this 
model, a low-volume hospital means a hospital identified by CMS as 
having fewer than 20 LEJR episodes in total across the 3 historical 
years of data used to calculate the performance year 1 CJR episode 
target prices.
    As noted in the previous paragraph, CMS provided rural and low-
volume hospitals in mandatory MSAs and all hospitals in voluntary MSAs 
a one time opt-in to continue in the model for PY 3 to PY 5. Of the 400 
hospitals eligible to opt-in to PY 3 to PY5, 91 hospitals opted in to 
continue participating. These 91 hospitals consist of 15 rural 
hospitals and 1 low-volume hospital in the 34 mandatory MSAs, and 75 
hospitals in the 33 voluntary MSAs. Five of the 75 hospitals in the 33 
voluntary MSAs are also classified as rural hospitals. As discussed 
later in this section, this final rule removes 139 voluntary, low 
volume, and rural hospitals from this model starting in PY 6 due to 
numerous hospitals in mandatory MSAs reclassifying as rural hospitals 
for wage index purposes. At the time of this final rule, an additional 
48 hospitals in the 34 mandatory MSAs have reclassified as rural.
    Hospitals volunteering to participate introduce selection bias 
because hospitals that are ready and able to participate and keep 
episode spending under the target price would likely select to continue 
in the model while

[[Page 23540]]

hospitals not able to keep episode spending under their target price 
would likely not participate. This conclusion is further supported 
given that, measured based on reconciliation payments, most opt-in 
hospitals financially benefited from participation in the CJR model in 
the first 2 performance years, which likely influenced their decision 
to continue participation in PY3 through PY5 of the model. We are 
evaluating the 75 hospitals who self-selected to continue participation 
in the model who are located in the 33 voluntary MSAs (voluntary opt-in 
hospitals) separately from our evaluation of the hospitals that were 
required to participate (mandatory hospitals) to avoid introducing 
selection bias into evaluation findings and improve generalizability of 
findings to all hospitals. It is costly to evaluate the small voluntary 
arm of the model for PYs 6 through 8 relative to the information that 
would be gained from the small sample size.
    In the February 2020 proposed rule, we proposed to change the 
definition of participant hospital so only participant hospitals with a 
CCN primary address in the 34 mandatory MSAs that are not considered 
low-volume or rural hospitals would continue in the model for the 
extension. We proposed to exclude participant hospitals in the 34 
mandatory MSAs that are low-volume hospitals or rural hospitals 
(meaning that the participant hospital received a notification from CMS 
dated prior to October 4, 2020 that they have been designated as a 
rural hospital), and other participant hospitals with a CCN primary 
address located in the 33 voluntary MSAs. We did not propose to provide 
any additional opt-in period for PYs 6 to 8 for previous participant 
hospitals that opted-in the CJR model, including low-volume hospitals 
and rural hospitals in the 34 mandatory MSAs, or for any hospitals 
located in the 33 voluntary MSAs. We designed the CJR model to require 
participation by hospitals in order to avoid the selection bias 
inherent in provider's choice of participation (80 FR 73278). Narrowing 
participation to hospitals in the 34 mandatory MSAs during the 3-year 
extension will allow CMS to minimize selection bias while evaluating 
the impact of the changes in this rule.
    At the time the proposed rule was issued, we believed that the BPCI 
Advanced model was an ideal fit for hospitals seeking to voluntarily 
participate in a clinical episode-based payment model for LEJR once CJR 
concluded. The BPCI Advanced model offered an LEJR episode that 
includes outpatient TKA procedures as of January 1, 2020. BPCI Advanced 
is a voluntary model and held its application period for participation 
as of January 1, 2020 during the spring and summer of 2019. This 
application period was open to acute care hospitals, physician group 
practices, and other entities such as post-acute care providers, and 
while CJR participant hospitals could not elect LEJR participation 
under the BPCI Advanced model for 2020, selecting to participate in at 
least one other BPCI Advanced bundled payment episode for 2020 would 
have allowed these providers to add LEJR episode participation at the 
end of their CJR model participation (the end of PY5). Since the CJR 
model originally was to have ended on December 31, 2020, we anticipated 
that any participant hospitals interested in pursuing voluntary 
participation in a bundled payment model already would have applied to 
participate in BPCI Advanced, of which 40 participant hospitals are 
concurrently participating in BPCI Advanced for non LEJR episodes.
    We proposed to use the notification date of the rural 
reclassification approval letter as the determining factor for 
participation in the CJR model for PYs 6 through 8, since it is an 
objective factor for determining participation based on rural 
reclassification. For PYs 6 through 8, we proposed that hospitals who 
applied for rural reclassification pursuant to 42 CFR 412.103 and have 
been notified by CMS before October 4, 2020 that their application for 
rural status has been approved will no longer be participating in the 
model beginning PY6 (that is, for any episodes beginning on or after 
October 4, 2020). We proposed that participant hospitals reclassified 
as rural that were notified that their application for rural status has 
been approved on or after October 4, 2020 (even if the effective date 
of the rural reclassification is retroactively effective prior to 
notification) would continue to participate in the CJR model for PYs 6 
through 8 and remain the financially accountable entities for PYs 6 
through 8. Rural reclassification requests that are submitted in 
accordance with Sec.  412.103 could take several months to be reviewed 
and approved by the CMS Regional Office. The CJR model team will make 
every effort to timely post an accurate list of PY5 participant 
hospitals identified as having rural status prior to the notification 
deadline on the CJR model page (https://innovation.cms.gov/initiatives/cjr) and will conduct email and/or phone outreach with these providers. 
Because the rural reclassification review process occurs on a rolling 
basis, we acknowledge that a delay in communication and notification 
may occur between the CMS Regional Office and the CJR model team. 
Accordingly, if hospitals who have been notified of their rural status 
before the notification deadline receive communications from the CJR 
model team that suggest their continued participation in the CJR model, 
it is only due to the delay in CMS internal communications between the 
CMS Regional Office and the CJR model team. The CJR model team will 
discontinue model communications to hospitals that were notified of 
rural status by CMS prior to the notification deadline as soon as the 
CJR model team is informed of the hospital's rural status. Any hospital 
who is notified of rural status prior to the notification deadline 
should disregard these CJR model communications as they do not suggest 
the hospital's continued participation in the model for PYs 6 through 
PY8.
    Comment: Many commenters expressed concern regarding the exclusion 
of rural and low-volume hospitals in the mandatory 34 MSAs and 
hospitals in the voluntary 33 MSAs from the CJR model extension, 
requesting that CMS either allow voluntary participants to continue 
participation in the CJR model or, in the alternative, open a new 
application cycle for BPCI Advanced. Commenters noted that voluntary 
hospitals did not apply to participate in BPCI Advanced because they 
were participating in the CJR model at that time and now the 
application period has closed leaving many hospitals without an option 
to join any bundled payment model for LEJR episodes. Some commenters 
believe that rural hospitals participating the CJR model that chose to 
opt-in will lose their ability to continue providing reductions in 
costs and improvements in care without continued support from CMS 
through the CJR model (including monthly data feeds, the ability to 
share savings with physicians and have the financial resources to 
maintain program oversight and population health management). Some 
commenters stated that the cost of care for patients who otherwise 
would have been included in the CJR model would increase, however they 
did not provide any evidence of how cost of care would increase for 
their patients, if they were no longer in the model. Other commenters 
suggested that excluding willing hospitals from participating in value-
based programs goes against the ideal and goals of moving the health 
care system from ``volume to value.''

[[Page 23541]]

    Response: We appreciate the concerns of the commenters and we 
understand that CJR participant hospitals that opted into the model may 
wish to continue; however, based on preliminary evaluation findings 
that will be included in the upcoming 4th year evaluation report the 
participation of voluntary hospitals resulted in significant net losses 
and therefore continuing to include these hospitals is likely to 
continue to reduce the overall cost savings of the model. When given 
the option of volunteering for a model, hospitals typically choose to 
participate when it is both financially advantageous and provides an 
opportunity to improve clinical care. A participant hospital's ability 
to earn reconciliation payments in connection with reduced FFS claims 
payments does not necessarily lead to overall Medicare savings as 
reconciliation payments are based on a target price established for 
broader hospital participation. Further, the continued cost to evaluate 
the small voluntary arm of the model is excessive relative to the 
information we would gather from a small sample that is not 
generalizable. Since the CJR model, as originally designed, would have 
ended on December 31, 2020, we anticipated that participant hospitals 
interested in pursuing voluntary participation in a bundled payment 
model already would have applied to participate in BPCI Advanced during 
that model's application period. For CJR participant hospitals that 
participate in BPCI Advanced in any episode other than joint 
replacement, these hospitals could have elected to participate in joint 
replacement episodes for CY 2021 when they are no longer in the CJR 
model. At the time this final rule is published, 139 hospitals will not 
continue in the model for PY6 through PY8. These 139 hospitals consist 
of 1 low-volume hospital, 63 rural hospitals, and 75 hospitals in 
voluntary MSAs. Further, for the 139 participant hospitals whose 
participation in the CJR model will end, 40 of these hospitals are 
enrolled in BPCI Advanced and could potentially join BPCI Advanced for 
LEJR. For hospitals who are unable to participate in either the CJR 
model or BPCI Advanced model, CMS is regularly reviewing opportunities 
for model development in the future and will alert hospitals of any 
opportunities that become available.
    Comment: Some commenters noted that selection bias should not be a 
factor in excluding participation of voluntary hospitals. A commenter 
recommended removing voluntary hospitals retrospectively from the 
larger sample for purposes of evaluation. Another commenter stated that 
CMS is simply renaming ``mandatory'' participants ``voluntary'' 
participants because these hospitals volunteered to remain in the CJR 
model after PY2 and therefore the argument regarding selection bias is 
unpersuasive. In contrast, MedPAC submitted comments recommending that 
CMS should focus on changes to the model that could generate net 
savings for the Medicare program.
    Response: CMS recognizes the commenters' concerns, however, the CJR 
model is largely a randomized, mandatory participation model. Once 
hospitals that were previously mandatory in PY 1 and PY 2 became 
voluntary in PY 3 and were given the opportunity to opt-in, selection 
bias was introduced since hospitals that were successful in the model 
chose to opt-in. All hospitals that were mandatory after the opt-in 
period continue to be mandatory for the extension except those 
hospitals that were reclassified as rural or are low-volume hospitals. 
CMS is not allowing any hospital that voluntarily opted into the model 
to continue participation for PYs 6 through 8. Likewise, the mandatory 
design presents CMS with a valuable opportunity to see what kind of 
utilization patterns occur in high-cost areas when providers are faced 
with strong incentives to reduce spending and cannot simply opt out of 
a model. As recommended by MedPAC, at this time, CMS is focused on 
changes to the model that could generate net savings for the Medicare 
program instead of redistributing savings back to providers. As 
previously indicated, internal analyses suggest that voluntary 
hospitals are less likely to contribute to potential model savings than 
mandatory hospitals.
    Comment: A couple of commenters inquired about the future of the 
CJR model and suggested that the model become a fully voluntary model 
after the 3-year extension. Further, commenters believe that the CJR 
model should be expanded nationally at the conclusion of the 3-year 
extension. For the 3-year extension, a commenter suggested instituting 
the CJR model in a larger number of areas, such as the 67 MSAs that 
were originally included in the model.
    Response: We appreciate the comment and will continue to monitor 
and evaluate model performance through the 3-year extension. Continuing 
with the 34 MSAs is a sufficient geographic scope to test the changes 
in the CJR model 3-year extension, while potentially reducing costs to 
Medicare. In its comment, MedPAC stated its belief that CMS should 
focus on changes to the model that could generate net savings for the 
Medicare program and therefore changing certain policies in the CJR 
model may allow Medicare to generate savings and increase the 
likelihood that the CJR model could expand after PY 8. Any potential 
expansion of the CJR model will be done via notice and comment 
rulemaking as required by section 1115A(c) of the Act.
    Comment: A commenter requested that CMS clarify what criteria would 
qualify a hospital as a low-volume hospital in the 34 mandatory MSAs.
    Response: Section 510.2 defines a low-volume hospital as a hospital 
identified by CMS as having fewer than 20 LEJR episodes in total across 
the 3 historical years of data used to calculate the PY1 CJR model 
episode target prices.
    Comment: A small number of commenters expressed concerns that the 
CJR model did not create enough incentives to avoid financial losses. 
These participant hospitals stated that they fulfilled their 
obligations and should now be afforded an opportunity to select 
participation based on their mission, abilities, and market realities. 
They stated that the CJR model extension creates greater risk for 
losses without giving the hospitals an opportunity to disengage from 
the model and recommended finding a way to reinvigorate the options of 
bundled arrangements with CMS.
    Response: We thank the commenters, however, CMS will continue to 
require hospitals in the 34 mandatory MSAs to participate in the CJR 
model because, based upon initial evaluation results for PYs 1 and 2, 
these geographic areas have significant opportunity for reducing 
episode spending while improving quality of care under the model. The 
34 mandatory MSAs have more opportunity because these are the medium 
and high cost areas and, therefore, there is significant opportunity 
for improvement. Similarly, we believe that at this point in the CJR 
model it is most prudent for us to continue the model in these 
geographic areas because these participant hospitals have already 
implemented infrastructure changes as well as received initial 
financial and quality results for the first four performance years.
    Comment: Some commenters provided recommendations for changes to 
the evaluation methodology. A commenter stressed the importance of 
incorporating health equity in the model evaluation approach and 
another requested that the evaluation include all

[[Page 23542]]

providers influencing the outcomes of patients in the CJR model.
    Response: CMS will continue to evaluate the impact of the model on 
vulnerable populations and investigate claims and utilization across 
the entire episode and also longer-term outcomes in the patient survey 
thereby capturing the influence of various providers on model outcomes.
    Comment: A commenter expressed concern about how the evaluation 
will differentiate the changes in cost due to the model and those 
driven by the ongoing transition in the care setting for services 
related to MS-DRG 469 and 470.
    Response: The model evaluation uses a difference-in-differences 
design to estimate the differential change in outcomes between the 
baseline and the intervention period for episodes initiated at CJR 
participant hospitals and hospitals relative to those initiated at 
control group hospitals. The difference-in-differences method controls 
for trends that may affect both CJR model and control group hospitals, 
such as major policy changes. In addition, the evaluation further 
adjusts estimates for beneficiary, market, and hospital characteristics 
that can vary over time and between the CJR model and control group.
    Final Decision: After consideration of the public comments we 
received, we are finalizing our policies with modification to account 
for PY6 start date as discussed in section II.D.1. of this final rule. 
The extension of PY5 impacts the proposed October 4, 2020 date used as 
a deadline for rural hospital status. Therefore, the new date will be 
July 4, 2021 to accommodate the revised start date of PY6, which is 
October 1, 2021.
    All hospitals with a CCN primary address located in the 33 
voluntary MSAs as well as hospitals with a CCN primary address in the 
34 mandatory MSAs that are low-volume or rural hospitals will be 
excluded from PYs 6 through PY8. Hospitals who applied for rural 
reclassification pursuant to 42 CFR 412.103 (rural hospitals include 
any scenario outlined in Sec.  412.103(a), which includes rural 
referral centers (RRCs) as set forth in Sec.  412.96) and have been 
notified by CMS before July 4, 2021 that their application for rural 
status has been approved will no longer be participating in the model 
beginning in PY6 (that is, for any episodes beginning on or after July 
4, 2021). Participant hospitals reclassified as rural that are notified 
that their application for rural status has been approved on or after 
July 4, 2021 (even if the effective date of the rural reclassification 
is retroactively effective to before July 4, 2021) will continue to 
participate in the CJR model for PYs 6 through 8 and remain the 
financially accountable entities for PYs 6 through 8. Rural 
reclassification requests that are submitted in accordance with Sec.  
412.103 could take several months to be reviewed and approved by the 
CMS Regional Office. The CJR model team will make every effort to post 
an accurate list of PY5 participant hospitals identified as having 
rural status prior to July 4, 2021 on the CJR model page (https://innovation.cms.gov/initiatives/cjr) and will conduct email and/or phone 
outreach with these providers. Accordingly, if hospitals who have been 
notified of their rural status before July 4, 2021 receive 
communications from the CJR model team that suggest their continued 
participation in the CJR model, it is only due to the delay in CMS 
internal communications between the CMS Regional Office and the CJR 
model team. The CJR model team will discontinue model communications to 
hospitals that were notified of rural status by CMS prior to July 4, 
2021 as soon as the CJR model team is informed of the hospital's rural 
status.

E. Participant Hospital Beneficiary Notification and Discharge Planning 
Notice

1. Participant Hospital Beneficiary Notification
    Under current regulations, the participant hospital detailed 
notification informs Medicare beneficiaries of their inclusion in the 
CJR model and provides an in-paper, detailed explanation of the model, 
either upon admission to the participant hospital if the admission is 
not scheduled in advance, or as soon as the admission is scheduled. We 
proposed to change the definition of an episode of care to include 
outpatient procedures, for which the beneficiary would not be admitted 
to the participant hospital. We also proposed to add the definition of 
anchor procedure to mean a TKA or THA procedure that is permitted and 
payable by Medicare when performed in the outpatient setting and billed 
through the OPPS. We believe that the beneficiary should be notified of 
his or her inclusion in the CJR model whether the procedure takes place 
in an inpatient or outpatient setting. Therefore, we proposed changes 
for the participant hospital detailed notification at 42 CFR 
510.405(b)(1) to clarify that if the anchor procedure or anchor 
hospitalization is scheduled in advance, then the participant hospital 
must provide notice as soon as the anchor procedure or anchor 
hospitalization is scheduled. Further, we proposed if the anchor 
procedure or anchor hospitalization is not scheduled in advance, then 
the notification must be provided on the date of the anchor procedure 
or date of admission to the anchor hospitalization.
    We currently state that in circumstances where, due to the 
patient's condition, it is not feasible to provide the detailed 
notification when scheduled or upon admission, the notification must be 
provided to the beneficiary or his or her representative as soon as is 
reasonably practicable but no later than discharge from the participant 
hospital accountable for the CJR model episode. We proposed to clarify 
that this policy applies only to inpatient hospital admissions. The 
purpose of this policy is to promote hospital care for the beneficiary 
first if it is not reasonably practicable to provide the notification 
upon admission. For example, if a beneficiary requires emergent care, 
the focus of the hospital should not be on providing a notification, 
but on the beneficiary. In contrast, outpatient procedures are 
generally scheduled and non-emergent. Therefore, we do not believe this 
policy is applicable to outpatient procedures, and did not propose to 
allow this type of beneficiary notification in cases of outpatient 
procedures.
    We believed these proposals would require changes to the 
participant hospital detailed notification provided on the CJR model 
web page. CMS will update the participant hospital notification model 
document accordingly.
    Comment: All commenters supported CMS' proposal that beneficiaries 
should be notified of their inclusion in the CJR model whether the 
procedure takes place in an inpatient or outpatient setting, noting 
that patients should be equipped with the information necessary to keep 
them engaged and make well-informed decisions about their care. Many 
commenters also noted that there is a narrow opportunity for hospitals 
to provide the participant hospital notification as patients do not 
come into the hospital until the day of the procedure, and that doctors 
should be allowed to provide participant notifications before the 
surgery instead of the CJR participant hospital. Some commenters that 
supported the proposed policy also recommended changing the time period 
when a participant hospital notification is required. Specifically, a 
couple of commenters requested to relieve the notification requirement 
for providing same day notification or allow for more time to provide 
the participant hospital

[[Page 23543]]

notification when the procedure is scheduled in advance. Also, a 
commenter requested more time to provide the notification citing CJR 
participant hospitals face difficulties in identifying which 
beneficiaries may qualify as CJR beneficiaries, which can prevent them 
from providing same day beneficiary notifications. Other commenters 
requested that CMS use less burdensome requirements for providers such 
as the BPCI Advanced model notification policy.
    Response: We appreciate commenters' support of our proposal to 
notify beneficiaries of their inclusion in the model whether the LEJR 
procedure is in an inpatient or outpatient setting. After considering 
commenters' requests to provide more expansive and less burdensome 
timeframes, we explored other Innovation Center models' beneficiary 
notification requirements. Specifically we considered BPCI Advanced's 
beneficiary notification policy, as BPCI Advanced is a similar episode 
based payment model where episodes can occur in an inpatient or 
outpatient setting. BPCI Advanced requires that prior to discharge from 
the inpatient stay or prior to the completion of the outpatient 
procedure, as applicable, the BPCI Advanced Participant shall ensure 
that the BPCI Advanced beneficiary receives a copy of a beneficiary 
notification. Therefore after evaluating comments and other Innovation 
Center policies, we are amending our beneficiary notification timing 
requirements so that prior to discharge from the anchor 
hospitalization, or prior to discharge from the anchor procedure, as 
applicable, the participant hospital must provide the CJR beneficiary 
with a participant hospital beneficiary notification. We believe that 
amending our proposal to incorporate BPCI Advanced's policy will allow 
CJR participant hospitals more time to provide the participant hospital 
beneficiary notification, streamline timing requirements and adhere to 
commenters' request to remove the requirement that a notification must 
be provided upon admission for an LEJR procedure or upon arrival for an 
outpatient LEJR procedure. In response to comments received, 
specifically in regards to the difficulties of identifying CJR 
beneficiaries, we are amending our policy allowing participant 
hospitals more time to provide the participant hospital beneficiary 
notification, in turn providing the participant hospital more time to 
identify the CJR beneficiaries.
    Comment: Some commenters supported CMS' proposal and recommended 
that CMS create one notification letter for all advanced APMs, 
including BPCI Advanced, noting that this would be less confusing for 
beneficiaries as they currently receive significant amounts of 
paperwork, and this would reduce the administrative burden placed on 
providers in multiple models.
    Response: We acknowledge the commenters' recommendation. We will 
consider these recommendations as the CJR model progresses and for 
future model development at the Innovation Center.
    Final Decision: After consideration of comments, we are finalizing 
our proposal with modification and will amend the timing requirements 
for the participant hospital beneficiary notification so that prior to 
discharge from the anchor hospitalization, or prior to discharge from 
the anchor procedure, as applicable, the participant hospital must 
provide the CJR beneficiary with a participant hospital beneficiary 
notification.
2. Discharge Planning Notice
    Under current regulations, a participant hospital must provide the 
beneficiary with a written notice of any potential financial liability 
associated with non-covered services recommended or presented as an 
option as part of discharge planning, no later than the time that the 
beneficiary discusses a particular post-acute care option or at the 
time the beneficiary is discharged, whichever occurs earlier (42 CFR 
510.405(b)(3)). Given our proposal as described in section II.A.2. of 
this final rule to change the definition of an episode of care to 
include outpatient procedures, for which the beneficiary would not be 
admitted to the participant hospital, we proposed to clarify the 
requirements of the discharge planning notice. We believe the 
beneficiary must be notified of his or her possible financial liability 
associated with non-covered post-acute care whether the procedure takes 
place in an inpatient or outpatient setting. Therefore, we proposed 
that a participant hospital must provide the beneficiary with a written 
notice of any potential financial liability associated with non-covered 
services recommended or presented as an option as part of discharge 
planning, no later than the time that the beneficiary discusses a 
particular post-acute care option or at the time the beneficiary is 
discharged from an anchor procedure or anchor hospitalization, 
whichever occurs earlier.
    Comment: A couple of commenters noted for outpatient episodes the 
discharge planning notification requirement is unclear and can become 
problematic when a discharge plan is uncertain at the time of procedure 
scheduling or when a previously discussed plan must be revised on the 
date of the procedure. These commenters ask CMS to consider revising 
the timing standard for the discharge planning notification, requiring 
only ``best efforts'' to provide notification by the time of discharge 
from the hospitalization or outpatient setting.
    Response: We appreciate the recommendations about the discharge 
planning notification. To be clear, we do not require the discharge 
planning notice to be provided at time of scheduling. We require the 
participant hospital provide the beneficiary with a written discharge 
planning notice either when a post-acute care option is discussed with 
the beneficiary or when the beneficiary is discharged from an anchor 
procedure or anchor hospitalization, whichever occurs earlier. We 
understand that some commenters find this policy problematic in that 
post-acute care plans can change after being discussed with a 
beneficiary. We understand that post-acute care plans can change after 
the first discussion, but providing the discharge plan notification to 
beneficiaries when plans are first discussed allows beneficiaries to be 
notified of potential financial liability associated with non-covered 
services recommended or presented as an option as part of discharge 
planning. Also, this allows beneficiaries to be aware of potential 
financial costs associated with post-acute care options whether or not 
the original discharge plan is followed.
    Final Decision: After consideration of public comments, we are 
finalizing our discharge planning notice requirements as proposed.

F. Quality Measures and Reporting

    The two quality measures included in the CJR model are the THA and/
or TKA Complications measure (NQF #1550) and the HCAHPS Survey measure 
(NQF #0166). The model also incentivizes the submission of THA/TKA PRO 
and limited risk variable data. We proposed to advance the 
Complications and HCAHPS performance periods for PYs 6 through 8 in 
alignment with the performance periods used for PYs 1 through 5. For 
PRO, we also proposed to advance the performance periods in alignment 
with previous performance periods as well as make changes to the 
thresholds for successful submission. We proposed to make these changes 
to the thresholds for successful submission as participant hospitals 
gain experience

[[Page 23544]]

with PRO and to continue the trend of increased thresholds set by the 
earlier performance years of the model. These proposed changes are 
outlined in Table 5.
    In response to the new start and end dates for PYs 6 through 8, we 
are finalizing Sec.  510.400(b)(4)) to reflect the revised pre- and 
post-op collection periods for PRO quality data. For PYs 6 through 8, 
CMS will extend the post-op PRO data collection window 2 additional 
months to accommodate for patients that may schedule post-op 
appointments beyond 365 days. This will allow an opportunity for 
participant hospitals to complete their post-op PRO assessment. The 
post-op PRO data collection window is normally from April 1st through 
June 30th every year; the new window will be from April 1st through 
August 31st. The extended window will total 14 months compared to the 
original proposed 12 month window. The start of post-op PRO data 
collection window for PY6 will remain unchanged, but will extend an 
additional 2 months (April 1, 2020 through August 31, 2021). However, 
as a result of the PY5 extension we will shift the PY6 pre-op PRO data 
collection window 1 year later than originally proposed to April 1, 
2021 through June 30, 2022 to align with the start and end dates of PY6 
through PY8. Please refer to section II.D.1. of this final rule for 
complete timeline changes to the 3-year extension of performance years.
BILLING CODE 4120-01-P

[[Page 23545]]

[GRAPHIC] [TIFF OMITTED] TR03MY21.008


[[Page 23546]]


[GRAPHIC] [TIFF OMITTED] TR03MY21.021

BILLING CODE 4120-01-C

[[Page 23547]]

    Comment: Several commenters did not support the proposal to 
increase the patient-reported outcomes submission thresholds in PYs 6, 
7 and 8 for pre-op and post-op data. Commenters expressed that the 
proposed increases were unrealistic and extreme, and that PRO 
submission continues to provide burden to the participant hospitals.
    Response: We thank the commenters for their remarks. In the 
November 2015 CJR final rule, we finalized a policy whereby the 
thresholds for successful submission increased as participant hospitals 
gained experience with PRO over the performance years. We stated our 
belief that having increased THA/TKA recipient data would result in a 
more reliable measure that is better able to assess hospital 
performance than a measure created from a less representative patient 
sample. Therefore, we finalized the requirement at 80 percent of the 
eligible elective primary THA/TKA patients. We believed acquisition of 
80 percent of the eligible elective primary THA/TKA patients would 
provide representative data for measure development while decreasing 
patient, provider and hospital burden. We believed that over time 
hospitals will become more adept at collecting this data, and it was 
reasonable to gradually increase the expected response rates to 
successfully fulfill the THA/TKA voluntary PRO and limited risk 
variable data collection and therefore proposed the increased changes 
to the thresholds for successful submission in order to obtain a more 
reliable measure.
    Due to lessons learned and feedback from current CJR participant 
hospitals, we are revising the threshold requirements down from 100 
percent as originally proposed. While PRO data submission is voluntary, 
to date participant hospitals have expressed challenges to reach 
current benchmarks in PY5 (>=80% or >=200 eligible procedures). Both 
participant hospitals and key stakeholders have commented that 
requiring 100 percent submission is neither feasible nor realistic for 
participant hospitals. As a result we are revising the thresholds as 
explained in Table 5a (Revised Performance Periods for Pre- and Post-
Operative THA/TKA Voluntary Data Submission), while also maintaining 
accountability of the PRO data collection from CJR participant 
hospitals.
    Comment: Some commenters support the continuation of the PRO 
measures in the CJR model extension stating the consistency of 
methodologies over the years overall minimizes the burden on 
participant hospitals and supports the efficacy of the model 
evaluation. A commenter suggested that CMS monitor any changes in 
patient outcomes now that outpatient surgeries have been added.
    Response: We thank the commenters for their support and 
suggestions. We will take these recommendations into consideration in 
our future measure development and testing efforts.
    Comment: A commenter suggested to include an adjuster to the 
Composite Quality Score (CQS) depending on the setting of the procedure 
(inpatient versus outpatient).
    Response: We thank the commenter for their support and suggestion. 
We will take this suggestion into consideration as a candidate for 
future inclusion in our measure development and testing efforts.
    Comment: Several commenters discussed suggestions to inform CJR 
participant hospitals if and when PRO measure data will be shared 
publicly. A few commenters stated they were discouraged by not 
receiving feedback about results to date. Commenters stated that it 
would be beneficial if CMS released a better means of reporting, which 
include live and robust dashboards with detailed data for quality 
review and improvement. A commenter recommended to move forward with 
testing of a TKA/THA PRO based performance measure.
    Response: We thank the commenters for their support and suggestion. 
We appreciate the desire for frequent data updates for this model. CMS 
is continuing to assess the results of the data submitted with goals of 
using the data for future measure development and reporting.
    Comment: Several commenters did not support or remained skeptical 
of the inclusion of HCAHPS in the CJR model because it is an overall 
measure of all patients receiving hospital services that is not 
specific to lower-extremity joint replacements. Therefore, the 
commenters contend HCAHPS does not reflect quality for targeted 
episodes of care. In addition, the commenters state the measure is too 
narrow because it only encompasses patient experience during the 
inpatient hospital stay and does not capture information about patient 
experience in the outpatient setting. For these reasons, commenters did 
not believe that the measure captures the correct information, and it 
will be of limited value to clinicians for quality improvement and 
limited opportunities to achieve the maximum quality points.
    Response: We appreciate the concerns from the commenters about the 
broad patient population covered by this measure. Although the HCAHPS 
Survey encompasses a broader range of patients than the model episode 
definitions, we are not aware of evidence that patient experience of 
care differs markedly from those of the larger group of eligible 
patients after patient-mix adjustment for service line (surgery) and 
age have been applied. Having all patients responding to the survey 
helps to inform hospitals on areas for improvement. We decline to adopt 
the commenters' suggestion to remove this component from of the CJR 
model composite quality score.
    Comment: A few commenters support advancing the HCAHPS measure in 
the CJR model extension stating the consistency of the quality measures 
allows participants to effectively carry over operational improvements 
they have already put in place.
    Response: We thank the commenters for their support and agree with 
their reasoning.
    Comment: Several commenters discussed suggestions to reconsider the 
appropriateness of the current components of the Composite Quality 
Score (CQS) to adjust for inpatient and outpatient procedures. They 
stated that there is a lack of measures of outpatient procedure 
outcomes in the CQS and that current measures are not ideal for 
outpatient procedures and will skew quality of care data.
    Commenters suggested adding the Forgotten Joint Score, Hospital-
level 30-day risk-standardized readmission rate (RSRR) following 
elective primary THA and/or TKA (NQF #1551) in the inpatient setting. 
Other commenters suggested to consider readmission rates, Excess Days 
in Acute Care (EDAC), Risk Standardized Hospital Visits within 7 days 
of Hospital Outpatient Surgery, and Hospital Visits after Hospital 
Outpatient Surgery (OP-36) in the outpatient setting.
    Commenters have also suggested adding additional CQS incentives for 
voluntary documentation of preventative tools, such as Risk Assessment 
and Predictive Tool (RAPT), and for participation in quality, risk 
variable, and PRO data submission to nationally recognized registries. 
Another commenter suggested CMS develop additional concepts to reward 
participants for tracking post-operation outcomes. Commenters also 
stated the current components of the CQS lack risk adjustment for 
sociodemographic status. Another commenter suggested CMS to consider 
using measures that would more accurately measure quality during the 
performance year in question. Finally, a commenter suggested CMS 
consider using a measure that would more accurately measure quality 
during the performance year in question.

[[Page 23548]]

    Response: We thank the commenters for their support and suggestions 
to implement quality measures across the care continuum. We did not 
propose alterations to the components of the CQS in the CJR model 3-
year extension, and we decline to adopt the commenters' suggestion that 
we do so now. We recognize that there may be some gaps in the current 
quality measures relative to other settings in which patients receive 
care. CMS does not provide recommendations for the setting where a 
procedure is performed. We will take these recommendations into 
consideration in our future measure development.
    Comment: A commenter suggested to adjust quality measures for 
COVID-19.
    Response: We appreciate the concern from the commenter about such 
adjustments. We have not made specific changes to data collection 
related to the COVID-19 PHE. However, in light of the IFC extensions, 
the pre-op and post-op collection windows have been adjusted to 
accommodate changes in performance year dates.
    Comment: Several commenters discussed suggestions to adjust the 
weighting of the CQS. The commenters suggested increasing the weighting 
of the PRO data submission component and eliminate or reduce the 
weighting of the HCAHPS. Other commenters suggested to eliminate or 
reduce the weighting of the HCAHPS and reassign the weighting to the 
TKA/THA complications component.
    Response: We thank the commenters for their suggestions. We did not 
propose alterations to the components of the CQS in the CJR model 3-
year extension and decline to adopt these suggested changes.
    Comment: Several commenters discussed several suggestions for CMS 
to improve the quality incentives of the CJR model. The commenters 
believed that CMS should shift to a payment system based on a 
participant's quality score from the pay for reporting system currently 
in place. The commenters argued it would help improve quality measures 
greatly among participants by increasing the financial incentives 
participants would receive.
    Response: CMS would like to thank to commenters for their 
suggestions. They will be taken into consideration for future change to 
the model or future models, if warranted.
    Final Decision: After consideration of the public comments we 
received, we are modifying the PRO and Risk Variable Submission 
Requirements to reduce the percentage and procedure PRO data submission 
thresholds for PYs 6 through 8. Please refer to Table 5a Revised 
Performance Periods for Pre- and Post-Operative THA/TKA Voluntary Data 
Submission. The post-op collection window for PYs 6 through 8 will be 
extended an additional 2 months. The extended window will total 14 
months compared to the original proposed 12 month window. The start of 
post-op collection window for PY6 will remain unchanged, but will 
extend an additional 2 months (April 1, 2020 through August 31, 2021). 
However, we will shift the PY6 pre-op collection window 1 year later 
than originally proposed to April 1, 2021 through June 30, 2022. We are 
also making a technical correction to Section 510.400(b)(2)(ii) 
introductory text by removing the phrase ``of the program'' and adding 
in its place the phrase ``of the model.''

G. Financial Arrangements: Elimination of 50 Percent Cap on Gainsharing 
Payments, Distribution Payments, and Downstream Distribution Payments

    Currently, participant hospitals may engage in financial 
arrangements under the CJR model. Starting with the November 2015 CJR 
model final rule (80 FR 73412 through 73437) participant hospitals have 
been allowed to enter into sharing arrangements to make gainsharing 
payments to certain providers and suppliers with which they were 
collaboratively caring for CJR beneficiaries and to allow CJR 
collaborators that are physician group practices to enter into 
distribution arrangements to share those gainsharing payments with 
certain PGP members. In the January 2017 final rule (82 FR 180) we 
finalized a full replacement of the prior CJR model regulations in 
order to revise and refine these requirements to allow for--(1) 
participant hospitals to enter into sharing arrangements with 
additional categories of CJR collaborators, including certain ACOs, 
hospitals, CAHs, NPPGPs and therapy group practices (TGPs); (2) ACOs, 
PGPs, NPPCGs and TGPs that are CJR collaborators to enter into 
distribution arrangements with certain entities and individuals; and 
(3) PGPs, NPPGPs and TGPs that received distribution payments from ACOs 
to enter into downstream distribution arrangements to share 
distribution payments with certain of their members. We believe these 
opportunities outlined in the January 2017 final rule (82 FR 531 
through 554) for the individuals and entities that engage in 
beneficiary care, care redesign and care management to share in the 
financial risk and rewards of the CJR model promote accountability for 
the quality, cost, and overall care for CJR beneficiaries.
    In order to ensure that goals of the CJR model are met, and to 
ensure program integrity and protection from abuse, the CJR model has 
many requirements for these financial arrangements. According to Sec.  
510.2 a gainsharing payment means a payment from a participant hospital 
to a CJR collaborator, under a sharing arrangement, composed of only 
reconciliation payments or internal cost savings or both; a 
distribution payment means a payment from a CJR collaborator that is an 
ACO, PGP, NPPGP, or TGP to a collaboration agent, under a distribution 
arrangement, composed only of gainsharing payments; and a downstream 
distribution payment means a payment from a collaboration agent that is 
both a PGP, NPPGP, or TGP and an ACO participant to a downstream 
collaboration agent, under a downstream distribution arrangement, 
composed only of distribution payments. Among other requirements, the 
CJR model has always included a cap on certain gainsharing payments and 
distribution payments to physicians, non-physician practitioners, and 
PGPs equal to 50 percent of the total Medicare approved amounts under 
the Physician Fee Schedule for items and services that are furnished to 
beneficiaries by that individual or entity during the performance year. 
As the CJR model has evolved, this cap has been retained and broadened 
to apply to gainsharing payments to NPPGPs, to distribution payments to 
non-physician practitioners, PGPs and NPPGPs, and to downstream 
distribution payments to non-physician practitioners and physicians. 
Accordingly, under the current regulations at Sec.  510.500(c)(4)(i) 
and (ii), the total amount of gainsharing payments for a performance 
year paid to physicians, non-physician practitioners, physician group 
practices (PGPs), and non-physician practitioner group practices 
(NPPGPs) must not exceed 50 percent of the total Medicare approved 
amounts under the Physician Fee Schedule for items and services that 
are furnished to beneficiaries during episodes that occurred during the 
same performance year for which the CJR participant hospital accrued 
the internal cost savings or earned the reconciliation payment that 
comprises the gainsharing payment being made. Distribution payments to 
these individuals and entities are similarly limited as specified in 
Sec.  510.505(b)(8)(i) and (ii), and downstream distribution payments 
are similarly limited as specified in Sec.  510.506(b)(8). However, 
based on comments received over the course of this model, our 
experience over time,

[[Page 23549]]

and our desire to allow consistent flexibilities across models, we 
proposed to eliminate these caps for episodes ending after December 31, 
2020.
    The need for the caps has been the subject of extensive comment 
since the start of the CJR model. In the initial CJR model proposal in 
July 2015 (80 FR 41198) we emphasized that the payment arrangements 
must be actually and proportionally related to the care of the 
beneficiaries in the CJR model and proposed a cap on gainsharing 
payments to individual physicians, non-physician practitioners, and 
PGPs equal to 50 percent of the Medicare-approved amounts under the PFS 
for items and services billed by that individual or PGP and furnished 
to the participant hospital's CJR beneficiaries. As discussed in the 
November 2015 final rule (80 FR 73420 through 73422), many commenters 
opposed the proposed cap on the total amount of gainsharing payments 
for a calendar year that could be paid to a PGP or an individual 
physician or non-physician practitioner who is a CJR collaborator, 
arguing that the 50 percent figure is arbitrary and should be removed. 
Other commenters asserted that a PGP that is a CJR collaborator should 
have the freedom to determine the most appropriate way to distribute 
gainsharing payments, given the multiple disciplines involved in 
patient care. Additionally, some commenters requested that internal 
cost savings be treated separately from reconciliation payments under 
the cap on gainsharing payments. Other commenters urged CMS to apply 
the same cap to the CJR model as is applied to Model 2 of the BPCI 
initiative. In our response, we acknowledged the many perspectives of 
the commenters on the proposed cap on gainsharing payments to 
physicians, non-physician practitioners, and PGPs in the CJR model. We 
stated that the purpose of the cap is to serve as a safeguard against 
the potential risks of stinting, steering, and denial of medically 
necessary care due to financial arrangements specifically allowed under 
the CJR model by providing an upper limit on the potential additional 
funds a physician, non-physician practitioner, or PGP can receive for 
their engagement with participant hospitals in caring for CJR model 
beneficiaries beyond the FFS payments that those suppliers are also 
paid and that are included in the actual episode spending calculation 
for the episodes. Moreover, we affirmed our intent to align the cap in 
the CJR model with the 50 percent cap on gainsharing payments to 
physicians and non-physician practitioners in the BPCI initiative, and 
noted that participants in BPCI had not voiced significant complaints 
that this moderate financial limitation had hampered their ability to 
engage physicians and non-physician practitioners in care redesign to 
improve episode quality and reduce costs. Accordingly, we concluded the 
50 percent cap on gainsharing payments was an appropriate condition for 
the CJR model at that time. This final rule also established a 
framework for distribution payments and applied the cap to those 
payments as well.
    In August 2016, when we proposed to expand the range of permissible 
financial arrangements to include additional parties and to allow for 
downstream distribution arrangements, we proposed to apply the 50 
percent cap to those payment arrangements well. As discussed in the 
January 2017 EPM final rule (82 FR 458 through 460), commenters were 
again of mixed views on these caps. While several commenters, including 
MedPAC, supported the caps, most commenters either recommended that CMS 
eliminate the caps for PGPs, eliminate the caps altogether for PGPs, 
physicians, and non-physician practitioners, or apply the caps on a 
different basis than CMS' proposal of 50 percent of the Medicare-
approved amounts under the PFS for items and services furnished by the 
physician or non-physician practitioner. In our response, we stated our 
continued belief that the caps served as a safeguard against the 
potential risks of stinting, steering, and denial of medically 
necessary care due to financial arrangements specifically allowed under 
the model. We again emphasized that we applied the 50 percent cap in 
both the CJR model and the BPCI initiative, and participants in neither 
model had voiced significant complaints that this financial limitation 
had hampered their ability to engage physicians, non-physician 
practitioners, and PGPs in care redesign to improve episode quality and 
reduce costs.
    In our subsequent CJR model rulemaking, we did not propose changes 
to the caps, but as described in the December 2017 final rule (82 FR 
57083), we again received comments both for and against these policies. 
Several commenters supported the current 50 percent gainsharing cap. 
Other commenters offered a variety of recommendations for changing the 
gainsharing limitations. In our response, we stated that we would 
continue to consider the issues raised by commenters as we moved 
forward with the CJR model and other models. Based on further 
consideration, we believe the commenters who opposed the caps presented 
the more compelling policy argument that these caps are arbitrary and 
limiting.
    The burdens associated with caps in the CJR model outweigh the 
potential benefits of these payment limitations. The caps were adopted 
and retained based on the belief that these limits on the potential 
financial rewards available via gainsharing payments, distribution 
payments and downstream distribution payments were needed to prevent 
physicians and non-physician practitioners from stinting, steering, and 
denial of medically necessary care. However, as we have continued to 
monitor the CJR participant hospitals and CJR model claims data we have 
not seen evidence suggesting that the financial arrangements in the CJR 
model have adversely impacted beneficiary access to care. We believe 
other limitations on the financial arrangements in the CJR model, 
including the express prohibitions in the CJR model regulations on 
financial arrangements to induce clinicians to reduce or limit 
medically necessary services or restrict the ability of a clinician to 
make decisions in the best interests of its patients, are sufficient 
and more reasonably targeted restrictions to prevent financial 
arrangements from resulting in the harms the caps were intended to 
address.
    Moreover, as commenters have consistently noted over the years, the 
caps in the CJR model constrain options to incentivize the clinicians 
who are supporting the care of CJR beneficiaries and participant 
hospitals and others incur administrative burden to monitor their 
compliance with these caps. Commenters previously argued that CJR 
collaborators should have the freedom to determine the most appropriate 
way to distribute gainsharing payments. Commenters contend the cap 
dampens the ability of gainsharing to support physician behavior change 
by reducing payments to a nominal amount. Accordingly, we believe 
maintaining these caps is unnecessary and unduly burdensome on the 
participant hospitals participating in the CJR model.
    Additionally, we note that in 2018 we revised our policies for BPCI 
Advanced such that BPCI Advanced Participants may execute an amendment, 
which would, among other things, eliminate the 50 percent cap on NPRA 
Shared Payments and Partner Distribution Payments (https://innovation.cms.gov/Files/x/bpciadvanced-my3-mutual-amendment.pdf). 
Previously, commenters stated that having different policies between 
models could create the potential for an uneven playing

[[Page 23550]]

field. Accordingly, the elimination of the caps in the CJR model would 
improve consistency across the CJR model and BPCI Advanced model. We 
believe that if the CJR model and BPCI Advanced model do not align, a 
consequence may be confusion among participants and sharing 
arrangements may not be used therefore impeding the CJR model's goal to 
support better and more efficient care for beneficiaries undergoing hip 
and knee replacements.
    We proposed to eliminate the 50 percent cap on gainsharing 
payments, distribution payments, and downstream distribution payments 
when the recipient of these payments is a physician, non-physician 
practitioner, physician group practice (PGP), or non-physician 
practitioner group practice (NPPGP) for episodes that begin on or after 
January 2, 2021. We proposed that these changes would apply to episodes 
on or after January 2, 2021 to align with the timing for the other 
policy changes we proposed in the proposed rule.
    We sought comment on our proposals to eliminate the 50 percent cap 
on gainsharing payments, distribution payments, and downstream 
distribution payments when the recipient of these payments are a 
physician, non-physician practitioner, physician group practice (PGP), 
or non-physician practitioner group practice (NPPGP).
    Comment: Several commenters support our proposal to eliminate the 
50 percent cap on gainsharing payments, distribution payments, and 
downstream distribution payments when the recipient of these payments 
are a physician, non-physician practitioner, physician group practice 
(PGP), or non-physician practitioner group practice (NPPGP). 
Specifically, MedPAC commented that although they previously supported 
inclusion of the 50 percent cap on gainsharing payments in the CJR 
model, MedPAC now supports CMS's proposal to eliminate the cap, and 
agrees with CMS that elimination of the cap reduces the administrative 
costs that hospitals and other entities incur in monitoring their 
compliance. MedPAC also agreed with CMS that the cap imposes an 
administrative burden that makes it more difficult for hospitals and 
other entities to provide gainsharing payments, and that the 
elimination the 50 percent cap would make the CJR model more consistent 
with the BPCI Advanced model, which simplifies CMS's oversight of the 
models. Further MedPAC and other commenters highlighted that CMS should 
continue to monitor the quality of care and the mix of beneficiaries 
who receive LEJR procedures to ensure that eliminating the cap on 
gainsharing payments does not lead to lower quality or patient 
selection. Lastly, MedPAC recommended that CMS should use evaluation 
methods in the 2019 CJR model evaluation report to evaluate whether 
eliminating the cap on gainsharing payments affects patient selection.
    Response: We appreciate the positive feedback on the proposed 
policy, and agree with commenters that eliminating the 50 percent cap 
reduces administrative cost, administrative burden and aligns with BPCI 
Advanced's policy. We acknowledge commenters' recommendation that CMS 
monitor participant hospitals and ensure that elimination of the cap 
does not have negative implications. As explained in the proposed rule, 
we monitor CJR participant hospitals and CJR model claims data closely 
and will continue these monitoring efforts to ensure eliminating the 
cap does not lead to lower quality care, patient selection bias, or 
other negative effects. Lastly, MedPAC's recommendation as to the 
evaluation of this policy is appreciated, and will be taken into 
consideration when evaluating future performance years.
    Comment: Some commenters that support the proposal to eliminate the 
50 percent cap noted their disappointment that the policy is limited to 
physicians, non-physician practitioners, physician group practices, and 
non-physician practitioner group practices because they believe post-
acute care providers, playing a key role in the CJR model, should be 
offered the same financial incentives. These commenters believe this 
proposal likely exacerbates disparate treatment of PAC providers in 
comparison to physicians regarding gainsharing payments.
    Response: We agree with the commenters that PAC providers play a 
key role in the CJR model. In this response, PAC providers include: 
Skilled Nursing Facilities; Home Health Agencies; Long Term Care 
Hospitals; Inpatient Rehabilitation Facilities; Therapist in private 
practice; Comprehensive Outpatient Rehabilitation Facility; a provider 
of Outpatient Therapy Services; Hospitals, Critical Access Hospitals; 
and Therapy Group Practices. PAC providers that are in CJR model 
financial arrangements have never had a cap on gainsharing payments, 
therefore, there was no need remove a cap that never existed. We 
appreciate the time and effort PAC providers put into the CJR model, 
however we disagree that our policy creates disparate treatment that 
negatively impacts them given PAC providers never had the cap on 
gainsharing payments.
    Comment: Several commenters made recommendations regarding 
financial arrangements that were not discussed in our proposal, such as 
mandating CJR participant hospitals to provide gainsharing 
opportunities and adding requirements that internal costs savings 
cannot be tied to joint implant pricing.
    Response: We appreciate the commenters' suggestions and may 
consider them in future model development.
    Final Decision: After consideration of the public comments we 
received, we are finalizing our proposed policies to eliminate the 50 
percent caps with a modification to account for the extension of PY5. 
We proposed regulatory text to eliminate the caps for episodes that 
begin on or after January 2, 2021 to align with the anticipated start 
of PY6. As discussed previously, after the publication of the February 
2020 proposed rule, we extended PY5 from December 31, 2020 to March 31, 
2021 in the April 2020 IFC, and then extended PY5 an additional six 
months to September 30, 2021 to account for the impact of the COVID-19 
PHE on CJR participant hospitals. Accordingly, in order for the 
proposal to eliminate the 50 percent caps on gainsharing payments, 
distribution payments, and downstream distribution payments when the 
recipient of these payments is a physician, non-physician practitioner, 
PGP, or NPPGP to take effect as intended for episodes that begin in 
PY6, the regulatory text implementing this proposal for episodes that 
begin on or after January 2, 2021 must be altered to account for the 
new end date of PY5. Therefore, we are finalizing our proposal as 
modified to eliminate the 50 percent cap on gainsharing payments, 
distribution payments, and downstream distribution payments when the 
recipient of these payments is a physician, non-physician practitioner, 
PGP, or NPPGP for episodes that end on or after October 1, 2021.

H. Waivers of Medicare Program Rules

    In the November 2015 final rule (80 FR 73273), we stated that it 
may be necessary and appropriate to provide additional flexibilities to 
participant hospitals in the model, as well as other providers that 
furnish services to beneficiaries in CJR model episodes. The purpose of 
such flexibilities is to increase CJR model episode quality and 
decrease episode spending or internal costs or both of providers and 
suppliers that results in better, more coordinated care for 
beneficiaries and improved financial efficiencies for Medicare,

[[Page 23551]]

providers, and beneficiaries. These additional flexibilities were 
implemented through our waiver authority under section 1115A of the 
Act, which affords broad authority for the Secretary to waive Medicare 
program requirements as may be necessary solely for purposes of 
carrying out section 1115A of the Act with respect to testing models.
    Section 510.610 of the regulations waives the 3-day hospital stay 
requirement before a beneficiary may be discharged from a hospital to a 
qualified SNF, which we define as a SNF that is rated an overall of 3 
stars or better for 7 of the last 12 months on the Nursing Home Compare 
website, but only if the SNF is identified on the applicable calendar 
quarter list of qualified SNFs at the time of the CJR beneficiary's 
admission to the SNF. The calendar quarter list of qualified SNFs is 
available under Participant Resources on the CJR model web page at 
https://innovation.cms.gov/initiatives/CJR. This waiver applies to 
episodes being tested under the CJR model beginning in PY2. All other 
Medicare rules for coverage and payment of Part A-covered SNF services 
continue to apply.
    In the December 2017 final rule (82 FR 180), we added additional 
protections in the event a CJR beneficiary is discharged to a SNF 
without a qualifying 3-day inpatient stay, but the SNF is not on the 
qualified list as of the date of admission to the SNF, and the 
participant hospital has failed to provide a discharge planning notice, 
as specified in Sec.  510.405(b)(3). We specified in that situation, 
CMS will make no payment to the SNF for such services; the SNF will not 
charge the beneficiary for the expenses incurred for such services; the 
SNF must return to the beneficiary any monies collected for such 
services; and the hospital must be responsible for the cost of the 
uncovered SNF stay.
    We proposed to extend these additional flexibilities to hospitals 
furnishing services to beneficiaries in the hospital outpatient setting 
as well. As discussed in section II.A.2. of this final rule, we 
proposed to change the definition of an episode of care to include 
procedures performed in the hospital outpatient department. We also 
proposed to add the definition of anchor procedure to mean a TKA or THA 
procedure that is permitted and payable by Medicare when performed in 
the hospital outpatient setting and billed through the OPPS. Therefore, 
based upon this proposal, when we use the term ``discharge'' under the 
Medicare Program Rule waivers, we intend for this term to apply to both 
anchor hospitalizations and anchor procedures.
    We do not anticipate that a beneficiary who receives a LEJR 
procedure in the hospital outpatient setting would generally need a SNF 
stay, since we expect that patients who are selected for outpatient 
LEJR procedures would generally be a healthier population than those 
who are selected for inpatient procedures. However, in the event that a 
participant hospital performs an LEJR procedure in the hospital 
outpatient setting and due to unforeseen circumstances, the beneficiary 
needs a SNF stay and has not had a qualifying 3-day inpatient stay, we 
do not want the beneficiary to be held financially liable for these 
costs. In accordance with section 1861(i) of the Act, beneficiaries 
must have a prior inpatient hospital stay of no fewer than 3 
consecutive days in order to be eligible for Medicare coverage of 
inpatient SNF care. We refer to this as the SNF 3-day rule. If this 
requirement is not met, then the beneficiary may be liable for the cost 
of the SNF stay. Additionally, we want to protect beneficiaries in the 
event that a participant hospital makes a choice that is based on 
billing, rather than on clinical needs. While this behavior is 
prohibited under the model and would actionable under Sec.  510.410, we 
proposed to add this additional safeguard so that a beneficiary would 
not be responsible for the expense. We proposed to amend Sec.  510.610 
by redesignating paragraphs (a) as (a)(1) and (a)(2), (a)(1) as (a)(2) 
and (a)(2) as (a)(3) and amending paragraph (b)(1) to reflect these 
proposals.
    Additionally, Sec.  510.600 of the regulations waives the direct 
supervision requirement to allow clinical staff to furnish certain 
post-discharge home visits under the general, rather than direct, 
supervision of a physician or non-physician practitioners. This waiver 
allows a CJR beneficiary who does not qualify for home health benefits 
to receive up to nine post-discharge visits in his or her home or place 
of residence any time during the episode. All other Medicare rules for 
coverage and payment of services incident to a physician's service 
continue to apply. We proposed to update Sec.  510.600(b)(1) so that 
this program rule waiver applies for LEJR procedures performed in the 
outpatient setting as well. As mentioned previously, when we use the 
term ``discharge'' under the Medicare Program Rule waivers, we intend 
for this term to apply to both anchor hospitalizations and anchor 
procedures.
    We sought comment on our proposals to apply CMS program rule 
waivers to LEJR procedures performed in the outpatient setting.
    Comment: Many commenters supported our proposal to extend the 
waiver of the SNF 3-day rule and direct supervision requirement to 
beneficiaries receiving an LEJR in the outpatient setting, noting that 
these waivers provide important services, as demonstrated through PYs 1 
through 5 and that CMS should attempt to maintain consistency between 
the original CJR model performance period and the extension when 
possible. Commenters urged CMS to finalize this policy as proposed, 
stressing that this policy accounts for unforeseen circumstances where 
beneficiaries need a SNF stay after receiving an LEJR procedure in the 
outpatient setting.
    Response: We appreciate commenters support to extend the waiver of 
the SNF 3-day rule and direct supervision requirement to beneficiaries 
receiving an LEJR in the outpatient setting, and agree with commenters 
that this policy maintains consistency into PYs 6 through 8 as well as 
accounts for unforeseen circumstances where beneficiaries need a SNF 
stay after receiving an anchor procedure. In general for the waiver of 
direct supervision, CMS waives the requirement in Sec.  410.26(b)(5) of 
this chapter that services and supplies furnished incident to a 
physician's service must be furnished under the direct supervision of 
the physician (or other practitioner) to permit home visits. The 
services furnished under this waiver are not considered to be hospital 
services, even when furnished by the clinical staff of the hospital. In 
Sec.  510.600(b), we specifically refer to circumstances of when this 
waiver may be used. Also as noted in Sec.  510.600(d), this waiver does 
not change other Medicare rules for coverage and payment of services 
incident to a physician's service. We note that in the CY 2020 OPPS/ASC 
final rule with comment period (CMS-1717-FC), we changed the generally 
applicable minimum required level of supervision for hospital 
outpatient therapeutic services from direct supervision to general 
supervision for services furnished by all hospitals, including Critical 
Access Hospitals (CAHs).
    Comment: A few commenters do not believe the waiver of the SNF 3-
day rule should be applied in the outpatient setting, noting that 
facilities performing outpatient procedures should send beneficiaries 
to home health or therapy because these cases should be less complex 
and require less intensive post-

[[Page 23552]]

acute care. Additionally, commenters requested clarification on the 
policy proposed and when and how the 3-day SNF waiver could be applied 
in the hospital outpatient setting. Also, commenters asked whether the 
stay billable by the SNF to Medicare Part A would be accounted for in 
calculating the episode.
    Response: We understand that generally a beneficiary receiving an 
LEJR procedure in an outpatient setting should not need a SNF stay and, 
as noted previously, we do not anticipate that a beneficiary who 
receives an LEJR procedure in the outpatient setting will need a SNF 
stay, and the use of the waiver in this circumstance will be seldom. 
However, in the event that a participant hospital performs an LEJR 
procedure in the outpatient setting and, due to unforeseen 
circumstances, the beneficiary needs a SNF stay and has not had a 
qualifying 3-day inpatient stay, we do not want the beneficiary to be 
held financially liable for these costs.
    We acknowledge the proposed language for coverage of a SNF stay 
after an anchor procedure was not clear and did not indicate a 
qualifying time period between the anchor procedure and SNF stay. 
Though we believe this waiver will unlikely be used, holding 
participant hospitals similarly accountable whether the waiver is used 
for an anchor hospitalization (in an inpatient setting) or for an 
anchor procedure (in an outpatient setting) provides consistency for 
participant hospitals in using the waiver. Therefore to provide 
consistency and clarification, we are amending the proposal for anchor 
procedures in that, for episodes being tested in PYs 6 through 8 of the 
CJR model, CMS waives the SNF 3-day rule for coverage of a SNF stay for 
a beneficiary who is a CJR beneficiary on or after 30 days of the date 
of service of the anchor procedure, but only if the SNF is identified 
on the applicable calendar quarter list of qualified SNFs at the time 
of the CJR beneficiary's admission to the SNF. CMS determines the 
qualified SNFs for each calendar quarter based on a review of the most 
recent rolling 12 months of overall star ratings on the Five-Star 
Quality Rating System for SNFs on the Nursing Home Compare website. 
Qualified SNFs are rated an overall of 3 stars or better for at least 7 
of the 12 months. Providing a 30 day window here is the same 
flexibility provided for anchor hospitalizations since when a CJR 
beneficiary receives an inpatient LEJR procedure, the 3-day SNF waiver 
is available for use within 30 days from the beneficiary's discharge 
date. This 30 day window is the current Medicare policy regarding SNF 
admission, specifically under Medicare beneficiaries must meet the ``3-
day rule'' before SNF admission. The 3-day rule requires the 
beneficiary to have a medically necessary 3-day-consecutive inpatient 
hospital stay and does not include the day of discharge, or any pre-
admission time spent in the emergency room (ER) or in outpatient 
observation, in the 3-day count. SNF extended care services are an 
extension of care a beneficiary needs after hospital discharge or 
within 30 days of their hospital stay (unless admitting them within 30 
days is medically inappropriate).
    Participant hospitals must correctly communicate to SNFs and 
beneficiaries (and/or their representatives) the number of inpatient 
days and outpatient stay, so all parties fully understand the potential 
payment liability.
    CMS will communicate new and revised policies to the Medicare 
Administrative Contractors and provide additional billing guidance to 
participant hospitals once processes are implemented. In amending the 
proposed policy, if a CJR beneficiary receives an outpatient LEJR 
procedure, the 3-day SNF waiver is available for use within 30 days 
from the date of service of the anchor procedure, but only if the SNF 
is identified on the applicable calendar quarter list of qualified SNFs 
at the time of the CJR beneficiary's admission to the SNF. Here, the 
SNF stay is covered under the waiver and billable by the SNF to 
Medicare. Also, this stay would be included in the episode cost, 
barring any other unknown variable. This waiver only applies to the 3-
day SNF rule, and therefore all other Medicare SNF coverage rules 
apply.
    Comment: Some commenters suggested CMS waive additional Medicare 
rules, such as the post-acute care transfer policy when beneficiaries 
are discharged to home health agencies (HHAs) that commit to 
coordinating with their hospital partners would help support care 
transitions without penalizing CJR participant hospitals.
    Response: We thank the commenters for their suggestions. We have 
not proposed to add additional waivers, but may consider these 
suggestions in future model development.
    Final Decision: After consideration of the public comments we 
received, we are finalizing our proposal to amend our policy regarding 
use of the 3-day SNF waiver for an outpatient LEJR episode at Sec.  
510.610. Specifically, for episodes being tested in PYs 6 through 8 of 
the CJR model, CMS waives the SNF 3-day rule for coverage of a SNF stay 
within 30 days of the date of service of the anchor procedure for a 
beneficiary who is a CJR beneficiary on the date of service of the 
anchor procedure, but only if the SNF is identified on the applicable 
calendar quarter list of qualified SNFs at the time of the CJR 
beneficiary's admission to the SNF.

I. Appeal Procedures

    In the November 2015 final rule (80 FR 73411), we finalized an 
appeal process for participant hospitals to dispute matters that are 
not precluded from administrative or judicial review. Under Sec.  
510.310(a), a participant hospital may appeal certain calculations 
related to payment by submitting a timely notice of calculation error. 
Participant hospitals must provide written notice of a calculation 
error within 45 days of the date the reconciliation report is issued if 
they believe a calculation error was made. A participant hospital may 
appeal CMS' response to the notice of a calculation error by requesting 
reconsideration review by a CMS official. The request for a 
reconsideration review must be received by CMS within 10 calendar days 
of the response to the notice of a calculation error. The 
reconsideration review request must provide a detailed explanation of 
the basis for the dispute and include supporting documentation for the 
participant hospital's assertion that CMS or its representatives did 
not accurately calculate the NPRA the reconciliation payment, or the 
repayment amount in accordance with Sec.  510.305. The reconsideration 
review is an on-the-record review (a review of briefs and evidence 
only); it is not an in-person hearing. Under the process we finalized 
in 2015, a CMS reconsideration official notifies the hospital in 
writing within 15 calendar days of receiving the participant hospital's 
reconsideration review request of the date, time, and location of the 
review; the issues in dispute; the review procedures; and the 
procedures (including format and deadlines) for submission of evidence 
(the ``Scheduling Notice''). The CMS reconsideration official must take 
all reasonable efforts to schedule the review to occur no later than 30 
calendar days after the date of the Scheduling Notice. The CMS 
reconsideration official issues a written determination within 30 days 
of the review. The determination is final and binding.
    We proposed to revise the Sec.  510.310(b)(4) to clarify that the 
reconsideration review process is an on-the-record review, not an in-
person review. The existing language at

[[Page 23553]]

Sec.  510.310(b)(4)(i) requires the reconsideration official to give 
hospitals the date, time, and location of the review. While we believe 
providing participant hospitals with information about the review is 
important, after careful review of the language we believe this 
language could cause confusion as to whether the participant hospital 
needs to attend the reconsideration review and whether the CJR model 
team will receive the Scheduling Notice and notice of the review 
procedures. Therefore, we proposed to remove paragraph (b)(4)(i) and to 
revise the introductory text of paragraph (b)(4) to clarify that the 
reconsideration official must notify both CMS and the hospital of the 
issues in dispute, the review procedures, and the procedures for 
submission of briefs and evidence. Additionally, we proposed to modify 
Sec.  510.310(b)(4)(iv) (which will be renumbered Sec.  
510.310(b)(4)(iii)) to clarify that the parties may submit briefs and 
evidence in support of their positions. The reconsideration official 
will conduct an on-the-record review of the briefs and evidence 
provided by the parties. We proposed to make conforming changes to 
delete Sec.  510.310(b)(5) (as it references a scheduled review in 
accordance with Sec.  510.310(b)(4)(i), which we proposed to delete) 
and to revise Sec.  510.310(b)(7) (which will be renumbered Sec.  
510.310(b)(6)) to state that the CMS reconsideration official issues a 
written determination within 30 days of the deadline for submission of 
all briefs and evidence. We sought comment on our proposal.
    Comment: A commenter supported CMS' proposal to clarify the 
language describing the appeals process.
    Response: We appreciate the commenter's support.
    Final Decision: After consideration of the public comment we 
received, we are finalizing the proposal without modification.

J. Request for Comment on New LEJR-Focused Models That Would Include 
ASCs and That Could Involve Shared Financial Accountability

    While we continue to believe that the CJR model is helping to 
improve care for joint replacements in the inpatient and outpatient 
hospital setting, we recognize that lower joint procedures are 
gradually being transitioned into ASCs. Specifically, in the CY 2020 
OPPS/ASC final rule (84 FR 61253), CMS finalized a proposal to add TKAs 
to the ASC covered procedures list. In the proposed rule we stated our 
belief that continued improvements and advances in medical technologies 
and surgical techniques could make ASCs an appropriate setting for THAs 
at a future point in time. Subsequently, in the CY 2021 OPPS/ASC final 
rule with comment period (85 FR 85866), CMS finalized a proposal to 
remove TAR and certain other orthopedic procedures from the IPO list 
and allow all procedures not on the IPO list to be paid when furnished 
in both the outpatient hospital and ASC settings. This means that all 
procedures included in the CJR model can, as of CY 2021, be performed 
in the ASC setting as well as the outpatient and inpatient hospital 
setting. Given that trends in care settings were continuing to 
transition in this direction at the time that the CJR February 2020 
proposed rule was published, we solicited comment on how we might best 
conceptualize and design a future bundled payment model focused on LEJR 
procedures performed in the ASC setting. Further, while the CJR model 
established hospitals as the financially accountable entity, we sought 
comment on how a new model could better recognize the role of the 
surgeons and clinicians in LEJR episodes. Who should participate in the 
model and should the reconciliation payment and/or repayment 
obligations be shared between the facility and the rendering surgeon to 
better encourage collaboration? Are there any other clinicians who 
should share directly in the financial accountability? In general, 
would a prospective bundled payment or a retrospective target price 
benchmarked payment model approach work best? What types of quality 
measures would participants need to track and report? Should the model 
be ASC specific or site-neutral such that inpatient, outpatient 
hospital and ASC service sites would be paid the same rate, regardless 
of where the procedure was performed?
    We appreciate the comments received and are taking each comment 
into consideration. We will continue to seek input from stakeholders as 
we consider future models that will incorporate ASCs.

K. April 2020 IFC and November 2020 IFC

    As discussed in section II.D.1. of this rule, the April 2020 IFC 
extended PY5 through March 31, 2021, and adjusted the extreme and 
uncontrollable circumstances policy to account for the COVID-19 PHE by 
specifying that all episodes with a date of admission to the anchor 
hospitalization that is on or within 30 days before the date that the 
emergency period (as defined in section 1135(g) of the Act) begins or 
that occurs through the termination of the emergency period (as 
described in section 1135(e) of the Act), actual episode payments are 
capped at the target price determined for that episode under Sec.  
510.300. Comments on these policies and our responses are outlined in 
sections II.G.2. and II.G.5. of the November 2020 IFC. In this final 
rule, we are finalizing the CJR related provisions in the April 2020 
IFC.
    In section II.G. of the November 2020 IFC, we implemented four 
changes to the CJR model. First, we extended PY5 an additional six 
months, so PY5 ends on September 30, 2021. Second, we made changes to 
the reconciliation process for PY5 to allow two subsets of PY5 to be 
reconciled separately. Third, we made a technical change to include MS-
DRGs 521 and 522 in the CJR episode definition, retroactive to 
inpatient discharges beginning on or after October 1, 2020, to ensure 
that the model continues to include the same inpatient LEJR procedures, 
despite the adoption of new MS-DRGs 521 and 522 to describe those 
procedures. Lastly, we made changes to the extreme and uncontrollable 
circumstances policy for COVID-19 to adapt to an increase in CJR 
episode volume and renewal of the PHE, while providing protection 
against financial consequences of the COVID-19 PHE after the extreme 
and uncontrollable circumstances policy no longer applies. We received 
five comments on the CJR related provisions in the November 2020 IFC. 
Comments on these policies and our responses are outlined in this 
section hereafter.
1. Extension of Performance Year 5 to September 30, 2021
    Comment: Commenters supported the extension of PY5 to September 30, 
2021 agreeing with CMS that if PY5 ended on March 31, 2021 it would 
create disruption to the model, which could be disruptive to hospitals 
and patient care, especially during the PHE. A commenter requested that 
we make the CJR model voluntary after March 31, 2021 or terminate the 
model due to the COVID-19 PHE. Another commenter requested that we 
extend PY5 to December 31, 2021 or until the end of the COVID-19 PHE in 
order to contain the impact of the COVID-19 PHE within PY5.
    Response: We agree with commenters that ending PY5 on September 30, 
2021 lessens the chance of disruption to the model and provides 
participant hospitals with additional relief and stability in model 
operations. We understand the commenter's concern in regards to the 
COVID-19 PHE and the progression of the model, but as we discussed in 
section II.D.1. of this final

[[Page 23554]]

rule, we believe this concern is alleviated by the extreme and 
uncontrollable circumstances policy that is in place to deal with CJR 
beneficiaries with a COVID-19 diagnosis after March 31, 2021. In 
addition, we considered extending PY5 to December 31, 2021, however, as 
noted previously the extreme and uncontrollable circumstances policy 
provides no downside risk for all participant hospitals that have an 
episode with a date of admission to the anchor hospitalization that is 
on or within 30 days before the date that the emergency period began 
until March 31, 2021 or the last day of such emergency period, 
whichever is earlier. This policy provides no downside risk for 
hospitals for the majority of 2020. Further, the new policy we adopted 
in the November IFC provides for no downside risk for CJR beneficiaries 
that have a COVID-19 diagnosis on a claim during a CJR episode for 
episodes that start on or after March 31, 2021, for the remainder of 
the model. As discussed in section II.G.5. of the November 2020 IFC, we 
believe these policies will still alleviate commenters' concern by 
containing the impact and financial risks to participant hospitals, as 
they operate the CJR model in conjunction with the COVID-19 PHE.
    Final Decision: After considering the comments received, we are 
finalizing without modification that PY5 extends to September 30, 2021. 
The definition of performance year reflects this finalization as well 
as incorporates the date ranges of PY6 through PY8 for the extension.
2. Additional Reconciliations for Performance Year 5
    Comment: Most commenters support the policy to conduct two 
reconciliations for PY5, specifying that conducting two reconciliations 
for PY5 in order to break up what would otherwise be a 21-month gap 
between reconciliation payments during the COVID-19 PHE is favorable to 
participant hospitals.
    Response: We appreciate the support by commenters and agree that 
providing two reconciliation periods allows participant hospitals the 
opportunity to receive a reconciliation payment, if applicable, on a 
timelier schedule rather than having an extended gap between 
reconciliation payments.
    Final Decision: After considering the comments received, we are 
finalizing without modification that, within PY5, CMS separately 
performs the reconciliation processes for PY subsets 5.1 and 5.2. This 
policy is finalized throughout 42 CFR part 510.
3. DRG 521 and DRG 522
    As outlined in section II.G.4. of the November 2020 IFC, we 
received 3 comments in response to the February 2020 proposed rule and 
20 comments in response to the FY 2021 IPPS/LTCH proposed rule 
addressing the effects of the proposed new MS-DRGs on the CJR model. 
For a discussion of those comments, please section II.G.4. of the 
November 2020 IFC (85 FR 71170 and 71171.
    Comment: Most commenters support the addition of MS-DRGs 521 and 
522, and the addition of these MS-DRGs to be retroactive to October 1, 
2020. Commenters highlighted that it is administratively simpler for 
CJR participant hospitals and associated surgeons to continue 
performing hip fracture THAs under the CJR model arrangements than to 
begin removing cases from the CJR model. Commenters also stated that 
maintaining hip fractures in the CJR model means those procedures 
remain subject to the value-based care incentives of the CJR model. A 
commenter on the November 2020 IFC, opposed the addition on MS-DRGs 521 
and 522, suggesting that CMS monitor the episodes mapped to the new MS-
DRGs and conduct periodic data analyses to ascertain the actual 
financial impact of the MS-DRG additions to the CJR model.
    Response: We appreciate the support of many commenters on adding 
MS-DRG 521 and 522 as of October 1, 2020 and agree that it is 
administratively simpler for CJR participants to continue performing 
hip fracture THAs under the CJR model arrangements than to begin 
removing cases from the CJR model. We agree that maintaining hip 
fractures in the CJR model means those procedures remain subject to the 
value-based care incentives of the CJR model. As discussed in section 
II.G.4. of the November 2020 IFC, we believe that failure to 
retroactively incorporate MS-DRGs 521 and 522 into the CJR model as of 
October 1, 2020 is detrimental to participant hospitals because it 
would have resulted in approximately 20-25 percent of all LEJR episodes 
to be dropped from the CJR model. The categories of episodes that may 
have been dropped tend to be associated with emergent surgeries, high-
costs, and complex post-acute care needs. Dropping these episodes from 
the model would have created confusion, and increased administrative 
burden for participant hospitals, and removed the opportunity for 
participant hospitals to earn reconciliation payments by coordinating 
care for these complex, high-cost episodes. Regarding the comment that 
CMS monitor the episodes mapped to the new MS-DRGs and conduct periodic 
data analyses to ascertain the actual financial impact of the MS-DRG 
additions to the CJR model, CMS currently monitors and completes 
analyses on MS-DRGs 521 and 522. This is because, historically, the CJR 
model episode definition included MS-DRG 469 (Major Hip and Knee Joint 
Replacement or Reattachment of Lower Extremity with MCC) and MS-DRG 470 
(Major Hip and Knee Joint Replacement or Reattachment of Lower 
Extremity without MCC). For purposes of calculating quality adjusted 
target prices, we further subdivided episodes within each MS-DRG based 
on the presence or absence of a primary hip fracture. Therefore, the 
creation of two new MS-DRGs, 521 and 522 (Hip Replacement with primary 
hip fracture, with and without major complications and comorbidities), 
respectively is a mere seamless transition for CMS to monitor these 
DRGs and operationally is a seamless transition for participant 
hospitals, which continue to bill Medicare FFS as usual for hip 
replacements with hip fractures. The new MS-DRGs are incorporated into 
the CJR episode reconciliation data system, and are included in 
participant hospitals' monthly data feeds.
    Final Decision: After considering the comments received, we are 
finalizing without modification that, as of October 1, 2020, the CJR 
model includes episodes when the MS-DRG assigned at discharge for an 
anchor hospitalization is one of two new MS-DRGs we adopted in the FY 
2021 IPPS/LTCH final rule (85 FR 58432): MS-DRG 521 (Hip Replacement 
with Principal Diagnosis of Hip Fracture with Major Complications and 
Comorbidities (MCC)) and MS-DRG 522 (Hip Replacement with Principal 
Diagnosis of Hip Fracture, without MCC).
4. Changes to Extreme and Uncontrollable Circumstances Policy for the 
COVID-19 PHE
    In the April 2020 IFC we developed an extreme and uncontrollable 
circumstances adjustment for the COVID-19 PHE to provide financial 
safeguards for participant hospitals that have a CCN primary address 
that is located in an emergency area during an emergency period, as 
those terms are defined in section 1135(g) of the Act, for which the 
Secretary issued a waiver or modification of requirements under section 
1135 of the Act on March 13, 2020, effectively applying the financial 
safeguards to all participant hospitals. These financial safeguards, 
wherein

[[Page 23555]]

actual episode payments are capped at the target price determined for 
that episode, applied to fracture or non-fracture episode with a date 
of admission to the anchor hospitalization that is on or within 30 days 
before the date that the emergency period (as defined in section 
1135(g) of the Act) begins or that occurs through the termination of 
the emergency period (as described in section 1135(e) of the Act). 
Ultimately, this policy removed downside risk for all participant 
hospitals until the COVID-19 PHE ends.
    We received comments on both the April 2020 IFC and the CJR 
February 2020 proposed rule about the extreme and uncontrollable 
circumstances adjustment, and responded to these comments in section 
II.G.5. of the November 2020 IFC. After consideration of comments as 
discussed in section II.G.5. of the November 2020 IFC, in the November 
2020 IFC, CMS amended the policy, such that for a fracture or non-
fracture episode with a date of admission to the anchor hospitalization 
that is on or within 30 days before the date that the emergency period 
(as defined in section 1135(g) of the Act) begins or that occurs on or 
before March 31, 2021 or the last day of such emergency period, 
whichever is earlier, actual episode payments are capped at the quality 
adjusted target price determined for that episode under Sec.  510.300. 
However, in order to account for CJR beneficiaries with a positive 
COVID-19 diagnosis during a CJR episode that initiates after March 31, 
2021 or the last day of the PHE, whichever occurs earlier, we capped 
actual episode payments at the quality adjusted target price for the 
episode, effectively waiving downside risk for all episodes with actual 
episode payments that include a claim with a COVID-19 diagnosis code.
    Comment: In regards to the extreme and uncontrollable circumstances 
policy for COVID-19 adopted in the November 2020 IFC, some commenters 
believe that CMS should revert back to the policy in the April 2020 IFC 
and waive downside risk for all episodes until the PHE ends. These 
commenters noted that though CMS portrayed LEJR procedures as being on 
the rise, hospitals are still experiencing a decline in LEJR procedures 
when comparing 2019 and 2020 data, and that the latest spike in COVID-
19 cases likely will depress that volume through the winter months so 
it continues to be appropriate to hold hospitals as risk bearing 
entities harmless from downside risk through the winter.
    Most commenters supported CMS' decision to develop a specific 
COVID-19 policy so participant hospitals are held harmless if a CJR 
beneficiary has a positive COVID-19 diagnosis during a CJR episode. A 
commenter asked when the beneficiary has to have COVID-19 in order for 
the financial safeguards to apply.
    Response: We appreciate the comments on the November 2020 IFC 
extreme and uncontrollable circumstances policy for the COVID-19 PHE. 
On January 7, 2021, the Secretary renewed the COVID-19 PHE effective 
January 21, 2021. Because the policy we adopted in the November 2020 
IFC provides that the downside risk waiver applies only to episodes 
with a date of admission to the anchor hospitalization that occurs on 
or before the earlier of March 31, 2021 or the end of the emergency 
period, and the emergency period now will extend beyond March 31, 2021, 
the extreme and uncontrollable circumstances policy set forth at Sec.  
510.305(k)(4) will not apply to episodes that are initiated on or after 
April 1, 2021.
    We understand commenters' concern about the PHE and recommendation 
that CMS should revert back to the policy in the April 2020 IFC, 
ultimately waiving downside risk for all episodes until the PHE ends. 
As noted previously, the current public health emergency was renewed 
effective January 21, 2021, and will be in effect for 90 days. Further, 
the Acting Secretary of Health and Human Services expressed to 
Governors that the PHE will likely remain in place for the entirety of 
2021, and that when a decision is made to terminate the declaration or 
let it expire, HHS will provide states with 60 days' notice prior to 
termination.\11\ In light of the continued renewal of the PHE, waiving 
downside risks for all episodes until the PHE ends could threaten the 
ability of the CJR model to generate any savings over the course of the 
model, especially given the potential for the PHE to remain in place 
for the entirety of 2021. Because the agency's authority to conduct 
models is constrained to those anticipated to reduce program 
expenditures, CMS is therefore unable to revert back waiving downside 
risk for all episodes until the PHE ends. Also, we understand the 
commenters' feedback that hospitals experienced a decline in LEJR 
procedures when comparing 2019 and 2020 data. However the difference in 
episodes volume is not only in response to the COVID-19 PHE, but also 
other factors such as LEJR procedures being performed in the outpatient 
and ambulatory surgery setting. Despite all factors, episode volume is 
experiencing an upward trend since June 2020 and averaging at 50 
percent or more when comparing episode volume between 2019 and 2020 
post June 2020. Table 5b depicts recent Medicare claims data comparing 
February to December of 2019 and February to November of 2020. These 
numbers reflect episode volume for each month, accounting for any CJR 
episode that began within that month.
---------------------------------------------------------------------------

    \11\ See. Public-Health-Emergency-Message-to-Governors.pdf 
(georgetown.edu).
[GRAPHIC] [TIFF OMITTED] TR03MY21.009

L. Coordination With Other Agencies

    Impacts created by payment changes under this model are entirely 
internal to HHS operations; coordination with other agencies is not 
required outside of the usual coordination involved in the publication 
of a HHS regulatory changes.

III. Collection of Information Requirements

    As stated in section 1115A(d)(3) of the Act, Chapter 35 of title 
44, United States Code, shall not apply to the testing and evaluation 
of models under section 1115A of the Act. As a result, the information 
collection requirements contained in this final rule need not be 
reviewed by the Office of Management

[[Page 23556]]

and Budget. However, we have summarized the information collection 
requirements in the Regulatory Impact Analysis section of this final 
rule.

IV. Regulatory Impact Analysis

A. Introduction

    We have examined the impacts of this final rule as required by 
Executive Order 12866 on Regulatory Planning and Review (September 30, 
1993), Executive Order 13563 on Improving Regulation and Regulatory 
Review (January 18, 2011), the Regulatory Flexibility Act (RFA) 
(September 19, 1980, Pub. L. 96-354), section 1102(b) of the Social 
Security Act, section 202 of the Unfunded Mandates Reform Act of 1995 
(March 22, 1995; Pub. L. 104-4), Executive Order 13132 on Federalism 
(August 4, 1999), and the Congressional Review Act (CRA) (5 U.S.C. 
804(2)).
    Executive Orders 12866 and 13563 direct agencies to assess all 
costs and benefits of available regulatory alternatives and, if 
regulation is necessary, to select regulatory approaches that maximize 
net benefits (including potential economic, environmental, public 
health and safety effects, distributive impacts, and equity). A 
regulatory impact analysis (RIA) must be prepared for major rules with 
economically significant effects ($100 million or more in any one 
year). This final rule implements proposed changes and extension of the 
CJR model; these provisions impact a subset of hospitals under the 
IPPS. The Office of Management and Budget has designated this final 
rule as an ``economically significant'' rule under E.O. 12866 and a 
``major rule'' under the Congressional Review Act (CRA).

B. Statement of Need

    Initial reports from the Innovation Center evaluation contractor as 
well as an independent study in the New England Journal of Medicine 
\12\ indicate that the model in PYs 1 and 2 resulted in modest cost 
reductions with quality of care maintained and no increases in case 
complication. Specifically, for PY1, without considering net 
reconciliation payments earned under the CJR model, the Innovation 
Center evaluation contractor observed that the total episode payments 
decreased 3.3 percent, or $910 per episode, more for CJR model episodes 
than control group episodes in the difference in difference 
analysis.\13\ Further, the second annual CJR model evaluation report, 
released on June 27, 2019, has found that CJR model episode payments 
decreased by 3.7 percent more over the first 2 years of the CJR model. 
These decreases in payments have likely reduced Medicare program 
spending over the first 2 performance years of the model by an 
estimated $17.4 million (with a range of Medicare losses of $41.1 
million to Medicare savings of $75.9 million, due to uncertainty in per 
episode savings).\14\ From these observations, it appeared that 
continuing to bundle lower joint payments would assist the Innovation 
Center in meeting its goal to reduce expenditures while preserving or 
enhancing the quality of care.
---------------------------------------------------------------------------

    \12\ Barnett, Wilcock, McWilliams, Epstein, et al. ``Two-Year 
Evaluation of Mandatory Bundled Payments for Joint Replacement'' see 
https://www.nejm.org/doi/10.1056/NEJMsa1809010.
    \13\ For the CJR first annual evaluation at a glance and full 
report see https://innovation.cms.gov/Files/reports/cjr-fg-firstannrpt.pdf and https://innovation.cms.gov/Files/reports/cjr-firstannrpt.pdf.
    \14\ For the CJR second annual evaluation at a glance and full 
report see https://innovation.cms.gov/Files/reports/cjr-fg-secondannrpt.pdf and https://innovation.cms.gov/Files/reports/cjr-secondannrpt.pdf.
---------------------------------------------------------------------------

    However, since these initial evaluation results, the traditional 
Medicare FFS program has shifted in ways that limit the model's long-
term ability to achieve savings, and we have determined that the 
changes adopted in this final rule are necessary for the following 
reasons. First, to address changes in the CY 2018 OPPS final rule (65 
FR 18455) to the IPO list (published annually in OPPS rule) to remove 
the TKA procedure code, as well as the recent removal of the THA 
procedure code from the IPO list in the CY 2020 OPPS final rule (84 FR 
61353), we proposed to change the definition of an Episode of care to 
include outpatient procedures for TKAs and THAs. Additionally, we 
believe it is necessary to adjust target pricing to ensure that target 
prices better capture spending trends and changes, by using more recent 
historical spending data that includes outpatient TKA and inpatient 
TKA/THA claims, as well as outpatient THA claims that will be included 
in CY 2021 and CY 2022 data, and in order to parallel the proposed 
changes to the reconciliation process with the changes we proposed to 
the target price calculations. We also proposed to conduct one 
reconciliation per CJR model performance year, which would be initiated 
six months following the end of a CJR model performance period. This 
change is intended to reduce the administrative burden of an additional 
reconciliation for Medicare and CJR participant hospitals. In an effort 
to remain consistent with BPCI Advanced, we proposed to eliminate the 
50 percent cap on gainsharing payments, distribution payments, and 
downstream distribution payments when the recipient of these payments 
is a physician, non-physician practitioner, PGP, or NPPGP for episodes 
beginning on or after April 1, 2016 and ending on or before December 
31, 2020 to remain consistent with the other policy changes made in the 
proposed rule. We believe that participant hospitals, CJR 
collaborators, collaboration agents, and downstream collaboration 
agents are now accustomed to the episode-based CJR model payment 
methodology and that administrative burden should be reduced and 
further flexibility should be offered to allow hospitals to share 
internal savings or earned reconciliation payments by removing the 
gainsharing cap. We proposed to adjust the composite quality score 
discount in recognition that the proposed changes to the target price 
calculation (discussed in section II.B. of this final rule), intended 
to increase the accuracy of target prices compared to actual 
performance period spending may also narrow the potential for 
participant hospitals to earn reconciliation payments. Because of these 
more accurate target prices, and the fact that all participant 
hospitals would be at financial risk during PYs 6 through 8, we 
determined that a more generous composite quality score adjustment to 
the discount factor is appropriate for hospitals ranked in the good and 
excellent CJR model quality categories.
    In this final rule we also note that the third annual CJR model 
evaluation report, released in November 2020, found that for mandatory 
CJR participant hospitals, the CJR model resulted in decreases in 
average payments for both the inpatient only and all LEJR episodes 
(inpatient and outpatient) during the first 3 performance years. 
Specifically, payments decreased by $1,378 more for all CJR model LEJR 
episodes (inpatient and outpatient) than for control group episodes, or 
4.7 percent from CJR model baseline payments. For the inpatient only 
episodes, payments decreased by $1,540 more than for control group 
episodes, or 5.3 percent from CJR model baseline payments. After 
accounting for the reconciliation payments, net savings from mandatory 
hospitals totaled $61.6 million (or 2 percent savings from baseline) 
for all LEJRs and $76.3 million (or 2.5 percent savings from baseline) 
for inpatient only episodes. From these recent observations, it 
continues to appear that bundling lower joint payments will assist the 
Innovation

[[Page 23557]]

Center in meeting its goal to reduce program expenditures while 
preserving or enhancing the quality of care.
    When we proposed this rule, we believed a 3-year extension was 
necessary to allow for enough time and information to reasonably 
evaluate the proposed changes. While the COVID-19 PHE will necessitate 
adjustments to the evaluation of the changes we are adopting in this 
final rule, we continue to believe they are improvements to the CJR 
model that will increase the probability of model savings compared to 
the original CJR model payment methodology (as described in Table 6a. 
of this final rule). Additionally, we continue to believe the CJR model 
promotes alignment of quality and financial accountability in the LEJR 
space and should continue to be tested through an extension of the 
model.

C. Anticipated Effects

    In prior sections of this final rule, we discuss our proposals to 
amend the regulations governing the CJR model. We present the following 
estimated overall impact of the proposed changes during the 3-year 
proposed extension. Table 7 summarizes the estimated impact for the 
proposed changes to the CJR model for the proposed 3-year extension of 
the model from April 1, 2021 through December 31, 2023. This table was 
created using 2018 claims data that was available at the time the 
proposed rule was published. Table 7a in this final rule is an updated 
version of the table calculated using 2019 claims data.
    There were approximately 470 providers participating in the CJR 
model as of October 2019. By limiting participation to the non-rural, 
non-low-volume providers physically located in the 34 mandatory MSAs, 
we expect approximately 330 participants in the CJR model for the 3-
year extension, dependent on changes in rural reclassification status 
or mergers. Specifically, we anticipate removing around 75 providers 
located in the 33 MSAs that were changed to voluntary and removing 
around 45 providers for rural reclassification status. For purposes of 
modeling this impact, using the 2019 Medicare claims data pulled from 
the Chronic Conditions Warehouse in February of 2021 and limiting the 
analysis to non-rural, non-low-volume providers located in the 34 
mandatory MSAs, we had 330 eligible providers with CJR model episode 
claims data. Projected CJR model episode volume increases from 2021 to 
2024 follow Medicare enrollment assumptions included in the 2020 
Medicare Trustees Report.\15\ Price updates for 2019 to 2020 follow FFS 
unit cost increases by service category for 2018 to 2020. The weights 
for each service category were developed using 2019 episode spending 
data. For 2021 to 2024, price updates were assumed to equal the market 
basket minus multifactor productivity (MFP) growth, or roughly the 
approximate price update that is built into the Trustees Report model.
---------------------------------------------------------------------------

    \15\ See page 176 of the 2020 Annual Report of the Board of 
Trustees of the Federal Hospital Insurance and Federal Supplementary 
Medical Insurance Trust Funds which can be found on: https://www.cms.gov/files/document/2020-medicare-trustees-report.pdf.
---------------------------------------------------------------------------

    We are assuming that participants would reduce episode spending by 
1 percent during PY6 due to their participation in the model. In PY7 
and PY8, we assume that participant hospitals' spending would grow at 
the same rate as spending by non-participating hospitals in their 
respective regions. We make these assumptions given that the most 
recent CJR model evaluation report showed that participant hospitals 
reduced spending by 5.3 percent for inpatient episodes during the first 
3 years of the CJR model. Specifically, we are assuming that 
participant hospitals will have more difficulty producing additional 
savings over time. Since LEJR episode costs have been declining, there 
is some uncertainty around how much more efficient participant 
hospitals, clinicians and the associated post-acute care providers can 
be in terms of further reducing the costs of LEJR episodes. However, as 
the CJR model shares the extra savings back to participant hospitals, 
we do not anticipate large changes in the impact analysis as a result 
of changes in the assumption that participant hospitals would have 
difficulty producing additional savings over time. We assumed that if 
the CJR model were not extended, participant hospitals would increase 
their episode spending by 2.65 percent as a response to the model 
ending, which is half of the savings shown by the evaluation for the 
first 3 years of the CJR model.
    We noted in the proposed rule that we did not make any assumptions 
about behavioral changes in the post-acute care space that may result 
from significant payment policy changes finalized in the FY 2019 SNF 
(83 FR 39162) and CY 2019 HH (83 FR 56406) rules for implementation 
with FY 2020 and CY 2020, respectively, as we did not yet have claims 
experience with these new methodologies in place. Behavioral changes 
stemming from these policies could have impacts upon our CJR model 
savings estimate that we were unable to quantify at that time. However, 
we have not updated our assumptions in this final rule about behavioral 
changes in the post-acute care space that may result from the payment 
policy changes noted previously since the COVID-19 PHE will likely 
impact the effect of these policies in CY 2020 claims data, and as 
noted in section II.B.3. of this final rule, we are omitting the use of 
2020 claims data for target price and risk adjustment coefficient 
calculations.
    While we are not using CY 2020 claims data to update our previous 
assumptions about behavioral changes in the post-acute care space that 
may have resulted from the payment policy changes referenced previously 
given the potential effect of the COVID-19 PHE on that data, we are 
adding certain assumptions to this final rule based on CY 2020 claims 
data because there is no other source of data to make these assumptions 
and they are also informed by CY 2018 and CY 2019 claims data. In 
particular, we used CY 2020 claims data to estimate the effect on 
overall LEJR spending in 2020 from two payment changes in 2020; the 
effect of the payment policy changes to TKA procedures performed in the 
ASC setting and THA procedures performed in the hospital outpatient 
setting, as described later in this section. We determined it 
appropriate to add these assumptions based on CY 2020 claims data since 
CY 2019 and prior year claims data does not include these two policy 
changes that only became effective in 2020. Additionally, we determined 
it appropriate to utilize CY 2020 data for this purpose since the 
overall LEJR spending and site of service utilization assumptions are 
also informed by data from CY 2018 and CY 2019. As noted later in this 
section regarding the effect on LEJR spending from THA procedures being 
performed in the outpatient setting in 2020, we did include basic 
considerations for the potential effect of the COVID-19 PHE on these 
general estimates. In contrast, we chose not to update assumptions 
about specific changes, such as behavioral changes in the post-acute 
care space, given the increased uncertainty of the magnitude and 
directional effect of COVID-19 PHE on those specific aspects of LEJR 
spending and since the assumptions would only be informed by CY 2020 
claims data (unlike the overall LEJR spending and site of service 
assumptions informed also by CY 2018 and CY 2019 data).
    TKA procedures in the ASC setting are eligible for Medicare payment 
as of January 1, 2020. In the OPPS CY 2020 final rule (84 FR 61388), we 
agreed with

[[Page 23558]]

commenters who stated that the majority of Medicare beneficiaries would 
not be suitable candidates to receive TKA procedures in an ASC setting, 
based on factors such as age, comorbidity, and body mass index that 
should be taken into account to determine if performing a TKA procedure 
in an ASC would be appropriate for a particular Medicare beneficiary. 
However, we further stated that we believe there are a small number of 
less medically complex beneficiaries that could appropriately receive 
the TKA procedure in an ASC setting and physicians should exercise 
clinical judgment when making site-of-service determinations, including 
for TKA. Since ASC procedures are not included in the CJR model 
extension, the agency's policy choice to allow Medicare payment for TKA 
procedures in the ASC setting could result in a decrease in the number 
of CJR model TKA episodes. However, we assume ASC procedures will only 
account for approximately five percent of LEJR procedures during the 
CJR model extension, and thus the changes in CJR episode volume would 
likely be small such that only the magnitude of this CJR model impact 
estimate would change. As noted previously, we determined it 
appropriate to utilize CY 2020 claims data to inform this assumption 
since 2020 is the first year TKA procedures in the ASC setting became 
eligible for Medicare payment.
    THA procedures were removed from the IPO list, effective January 1, 
2020. We acknowledge that it is possible this change could result in 
reductions in THA episode costs should some percentage of inpatient THA 
procedures move into the OPPS setting over the next several years. 
Analysis of 2020 claims data from an external analytic contractor 
indicates during 2020, THA procedures in the OPPS setting accounted for 
approximately 10 percent of all LEJR episodes. Additionally, compared 
to inpatient THA episodes, episode spending for THA procedures in the 
OPPS setting was approximately 30 percent less in 2020. We assume the 
reduction in episode costs for THA procedures in the OPPS setting 
during 2020 was partially a result of the effect of the COVID-19 PHE, 
which likely had the effect of shifting less complex and costly 
patients to the OPPS setting in an effort to avoid inpatient hospital 
utilization. Therefore, we assumed overall LEJR spending decreased by 2 
percent in 2020 as a result of this setting change.
    The calculations shown in Table 7 estimated that, in total, the 
proposed changes to the CJR model would result in a net Medicare 
program savings of approximately $269 million over the 3 proposed 
performance years (2021 through 2023). We sought comment on our 
assumptions and approach. The updated calculations shown in Table 7a in 
this final rule estimated that, in total, the changes we are adopting 
in this final rule to the CJR model would result in net Medicare 
program savings of approximately $217 million over the 3 proposed 
performance years (2021 through 2024).
    The following Table 6 summarizes the anticipated impact of certain 
provisions of this final rule. While the table does not include all the 
provisions in this final rule, it includes those provisions for which 
we determined there was the potential for a significant change in costs 
or savings related to a change in the model's major policies. We did 
not include policies for which we determined there would not be the 
potential for changes in costs or savings, such as the removal of the 
gainsharing caps that were in place PYs 1 through 5. We were unable to 
provide discrete estimates associated with each of these provisions at 
the time the proposed rule was published due to lack of calendar year 
2019 claims data availability. This table includes a qualitative 
estimate of the possible costs/savings to Medicare resulting from each 
provision in this final rule. The ``Notes'' column provides additional 
background when necessary.

[[Page 23559]]

[GRAPHIC] [TIFF OMITTED] TR03MY21.010


[[Page 23560]]


[GRAPHIC] [TIFF OMITTED] TR03MY21.011


[[Page 23561]]


    We are updating Table 6 from the proposed rule with Table 6a, which 
includes a discussion of the transfer amounts for certain provisions in 
this final and the considerations that frame the assumptions for each 
provision. While we noted in the proposed rule that Table 6 would 
reflect the transfer amounts relative to the original CJR model 
provisions, we are clarifying that the transfer amounts included in 
Table 6a are transfer amounts of each provision relative to the CJR 
model extension payment methodology with or without that provision. 
This clarification is also noted in the Transfers column in Table 6a in 
this final rule. We chose to display the transfer amounts this way 
after we determined that certain provisions in the CJR model extension 
methodology were incomparable to the original CJR model methodology and 
could lead to misleading transfer amount assumptions. Additionally, 
certain provisions in the final rule would have different impacts if 
applied to the original CJR model methodology together or separately.
    For example, as a result of the SNF PDPM that was implemented on 
October 1, 2019 (83 FR 39162), we have observed changes in average SNF 
episode costs in CJR model episodes. Under the CJR model methodology, 
which utilizes the most recent 3 years of data for target price 
calculations and updates that data every other year and updates target 
prices twice annually for prospective payment systems updates, we would 
not completely account for the effect of the SNF PDPM payment change in 
PYs 6 through 8. Specifically, the 3 years of historical data would 
only include a portion of time when the new PDPM was implemented (as 
PY6 target prices would be calculated with 2016-2018 data and PY7 and 
PY8 target prices would be calculated with 2018-2020 data), and the 
twice annual updates in the CJR model original methodology that would 
include a SNF Services Update Factor would not be correctly updated 
because that methodology relies on the former RUG-IV Case-Mix Adjusted 
Federal Rates. This would create inaccurate target prices, which could 
lead to higher model transfer costs if the effect of the SNF PDPM 
payment change would be to lower target prices. While the provision to 
rely on only the most recent year of historical data for target price 
calculations would help remedy this and could lead to model transfer 
savings, the market trend factor would also help eliminate the delay in 
adjusting for lower SNF episode costs in historical target pricing 
data. While we consider all the provisions as improvements related to 
the original CJR model methodology, which are meant to generate 
transfer savings or zero amounts, the transfer assumptions in Table 6a 
are relative to the CJR model extension methodology with or without 
each provision; they are not relative to the original CJR model 
provisions.

[[Page 23562]]

[GRAPHIC] [TIFF OMITTED] TR03MY21.012


[[Page 23563]]


[GRAPHIC] [TIFF OMITTED] TR03MY21.013


[[Page 23564]]


[GRAPHIC] [TIFF OMITTED] TR03MY21.014


[[Page 23565]]


    Burden reductions should result from other proposals. Specifically, 
we proposed the move from two to one reconciliation should effectively 
cut the level of effort participants and the agency need to expend on 
reconciliation in half. Assuming a rate of $33.89 per hour for an 
accountant (https://www.bls.gov/ooh/business-and-financial/accountants-and-auditors.htm) and an average of 15 hours to review each report for 
each of the 474 participant hospitals at 2 months then again at 14 
months could cost approximately $481,916. Moving to only one report for 
each performance year should reduce that cost by $240,958 to 
approximately $240,958. Likewise, accounting hours necessary to ensure 
that no physician received more than 50 percent of his or her total 
billing for Medicare-approved amounts under the PFS for items and 
services furnished by that physician or non-physician practitioner to 
the participant hospital's CJR beneficiaries during CJR model episodes 
that occurred during the same performance year for which the 
participant hospital accrued internal cost savings or earned a 
reconciliation payment will no longer be necessary should our proposal 
to remove the 50 percent cap be finalized. Given our most recent 
review, 159 CJR participant hospitals have CJR collaborators that are 
physicians. Assuming an average of 10 collaborators per participant and 
20 hours to review each collaborator's Part B claim totals by 
accountants at an hourly rate of $33.89, each participant could have 
spent approximately $6,778 on the reviews for a total of $1.1 million 
across all 159 participants with CJR collaborators. Our proposal to 
remove the 50 percent cap should therefore reflect a burden reduction 
around $1.1 million. While we are unable to quantify the change to be 
had by our proposals to modify beneficiary notice requirements for 
model inclusion, discharge planning notices, and our extension of 
waivers for Medicare program rules, we believe having uniform 
requirements regardless of procedure setting for CJR beneficiaries will 
help participants to streamline the administrative procedures they put 
in place for the CJR model and that this streamlining will reduce the 
effort participants need to expend in complying with the CJR model 
regulations.
[GRAPHIC] [TIFF OMITTED] TR03MY21.015

    Our analysis in Table 7 from the proposed rule was informed by the 
target price and episode spending calculations produced by an external 
analytic contractor using 2018 claims data and presented the transfer 
payment effects of the proposed rule to the best of our ability. The 
updated analysis in Table 7a in this final rule was informed by 
calculations produced by the same external analytic contractor using 
2019 claims data and presents the updated transfer payment effects of 
the final rule to the best of our ability.
[GRAPHIC] [TIFF OMITTED] TR03MY21.016

    The following Table 8 summarizes the financial impact of the 
proposal across 3 relevant years as well as two alternative scenarios: 
(1) If the CJR model were discontinued; and (2) if the CJR model were 
extended with changes to the episode definition to include outpatient 
TKA/THA but no other proposed changes. This table includes the full 
amount of FFS episode payments and any rows that show the model 
extending also includes any reconciliation payments related to the 
model. This table shows costs/savings (costs are represented as 
positive amounts and savings as negative amounts) imposed on non-
federal entities (that is, participating medical facilities) as well as 
net transfers of federal funds (that is, increases in Medicare program 
expenditures are indicated as positive amounts and decreases in 
Medicare program expenditures are indicated as negative amounts).

[[Page 23566]]

[GRAPHIC] [TIFF OMITTED] TR03MY21.017

    In this final rule, we have updated Table 8 with Table 8a, based on 
the new assumptions regarding financial impact of the CJR model noted 
in Table 7a. We excluded impact assumptions for the alternative 
scenario from Table 8, (2) if the CJR model were extended with changes 
to the episode definition to include outpatient TKA/THA but no other 
proposed changes, in Table 8a since we determined this scenario is not 
practically feasible. As noted in section II.C.6. of this final rule, 
many of the CJR model payment methodology changes CMS is adopting in 
this final rule for PYs 6 through 8 are interdependent, and we believe 
will only be successful if implemented together. We determined it is 
not practical to consider scenario (2), adding outpatient TKA/THA to 
the episode definition with none of the other proposed changes, because 
the CJR model extension payment methodology relies on the risk 
adjustment mechanism to appropriately account for the variation in 
inpatient procedure costs compared to the OPPS setting. Additionally, 
similar to the updates to Table 6a in this final rule, we determined 
comparing certain provisions of the CJR model extension methodology to 
the original CJR model methodology could lead to misleading transfer 
amount assumptions.
[GRAPHIC] [TIFF OMITTED] TR03MY21.018

    We received no comments about the anticipated financial effects 
specified in the proposed rule or about our assumptions and approach 
regarding Table 7 or Table 8. We have provided approximate updates to 
these tables based on our current assumptions regarding the LEJR market 
environment.

D. Effects on Beneficiaries

    We believe the refinements to the CJR model adopted in this final 
rule would not materially alter the potential effects of the model on 
beneficiaries. We believe the changes would not alter the effects of 
the model on beneficiaries because the changes predominantly alter how 
hospitals interact with the model, rather than how beneficiaries 
receive care. We do not expect that CJR participant hospitals will 
conduct a larger share of LEJR procedures in the outpatient setting 
than non-CJR participant hospitals. We believe that the combination of 
our episode-level risk adjustment methodology, with the fact that 
sicker patients who are inappropriately treated in the outpatient 
setting would potentially have complications requiring readmissions or 
other expensive post-acute care as a result of the inappropriate care 
setting for the original procedure, will incentivize physicians to make 
the appropriate clinical judgment based on the individual beneficiary's 
needs.
    We received no comments on this section of the proposed rule and 
therefore are finalizing this section without modification.

E. Effects on Small Rural Hospitals

    Section 1102(b) of the Act requires CMS to prepare a RIA if a rule 
may have a significant impact on the operations of a substantial number 
of small rural hospitals. This analysis must conform to the provisions 
of section 604 of the RFA. For purposes of section 1102(b) of the Act, 
a small rural hospital is defined as a hospital that is located outside 
of an MSA and has fewer than 100 beds. We note that, according to this 
definition, the CJR model has never included any rural hospitals given 
that the CJR model only includes hospitals located in MSAs. However, 
for purposes of our policy to provide a more protective stop-loss 
policy for certain hospitals, in the November 2015 final rule we 
revised our definition of a rural hospital to include an IPPS hospital 
that is either located in a rural area in accordance with Sec.  
412.64(b) or in a rural census tract within an MSA defined at Sec.  
412.103(a)(1), or has reclassified to rural in accordance with Sec.  
410.103.
    The changes to, and extension of, the CJR model as laid out in this 
final rule are focused on high cost urban area MSAs and exclude 
participant hospitals that are rural hospitals as of July 4, 2021 from 
participation. We note that the hospitals with rural status that opted 
to continue to participate in the CJR model after February 1, 2018 were 
defined as rural based on their urban to rural reclassifications 
governed by Sec.  412.103 and were also qualified as rural referral 
centers (RRCs) (see Sec.  412.96), which are high-volume acute care 
hospitals that treat a large number of complicated cases. None of these 
hospitals were geographically rural for purposes of section 1102(b) of 
the Act. Therefore, we are not preparing an analysis for section 
1102(b) of the Act because we have

[[Page 23567]]

determined, and the Secretary certifies, that the changes to, and 
extension of, the CJR model will not have a significant impact on the 
operations of a substantial number of small rural hospitals. We 
received no comments on this section of the proposed rule and therefore 
are finalizing this section without modification.

F. Effects on Small Entities

    The RFA requires agencies to analyze options for regulatory relief 
of small entities, if a rule has a significant impact on a substantial 
number of small entities. For purposes of the RFA, small entities 
include small businesses, nonprofit organizations, and small 
governmental jurisdictions. We estimated that most hospitals and most 
other providers and suppliers are small entities, either by virtue of 
their nonprofit status or by qualifying as small businesses under the 
Small Business Administration's size standards (revenues of less than 
$8.0 to $ 41.5 million in any one year; NAIC Sector-62 series). States 
and individuals are not included in the definition of a small entity. 
For details, see the Small Business Administration's website at https://www.sba.gov/document/support-table-size-standards. For purposes of the 
RFA, we generally consider all hospitals (NAICS code 622110 or 622310) 
and other providers and suppliers to be small entities. We believe that 
the provisions of this final rule relating to acute care hospitals will 
have some effects on a substantial number of other providers involved 
in these episodes of care including surgeons and other physicians 
(NAICS code 621111), SNFs (NAICS code 623110), physical therapists 
(NAICS code 621340), and other providers. Although we acknowledge that 
many of the affected entities are small entities, and the analysis 
discussed throughout this final rule discusses aspects of the CJR model 
that may or would affect them, we have no reason to assume that these 
effects would reach the threshold levels of 3 or five percent of 
revenues used by HHS to identify what are likely to be ``substantial'' 
or ``significant'' impacts, respectively.
    Using the table of Small Business Size Standards Matched to NAICS 
codes released by the U. S. Small Business Administration,\16\ we 
determined that HHAs are considered small businesses if annual revenues 
are less than $16 million, and SNFs are considered small businesses if 
annual revenues are less than $20 million. Using the Medicare Cost 
report data from 2017,\17\ only 353 HHAs of the 10,413 that filed cost 
reports were not considered small businesses. Similarly, only 1,199 
SNFs of the 14,764 that filed cost reports were not considered small 
businesses. CJR model historical experience has demonstrated that HHAs 
benefit from the model through increased referrals and HHA utilization. 
While the CJR Model Third Annual Evaluation Report could not draw 
conclusions on the model's effect on HHA payments, it does note that 
the proportion of CJR patients first discharged to an HHA increased 
21.9% from the CJR baseline proportion during PYs 1-3.\18\ In contrast, 
SNFs experience decreases in overall Medicare payments compared to 
baseline estimates (15.4 percent during PYs 1-3) as a result of the 
model.\19\ While the Evaluation Report indicates the model affected 
these entities as such, only a small proportion of the total bed days 
in SNFs are covered by Medicare, which limits the degree of impact on 
the overall revenues of those entities. Based on 2017 cost report data, 
only 12.9 percent of all bed days in SNFs were covered by Medicare FFS 
while Private Payer, Managed Care and Medicaid accounted for the 
remaining 87.1 percent.\20\ Additionally, although LEJR procedures (MS-
DRGs 469 and 470) are among the most common surgical procedures 
undergone by Medicare beneficiaries, they are only about 5 percent of 
all acute hospital discharges.\21\ We assume that all or almost all of 
these entities will continue to serve these patients, and to receive 
payments commensurate with their cost of care. Hospitals currently 
experience frequent changes to payment (for example, as both hospital 
affiliations and preferred provider networks change) that may impact 
revenue, and we have no reason to assume that this will change 
significantly under the changes.
---------------------------------------------------------------------------

    \16\ U.S. Small Business Administration: Table of Small Business 
Size Standards Matched to North American Industry Classification 
System Codes is accessible at: https://www.sba.gov/sites/default/files/2019-08/SBA%20Table%20of%20Size%20Standards_Effective%20Aug%2019%2C%202019_Rev.pdf.
    \17\ 2017 Medicare Cost Report data accessible at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Cost-Reports.
    \18\ See pg. 61 of the CJR Model Third Annual Evaluation Report 
accessible at: https://innovation.cms.gov/data-and-reports/2020/cjr-thirdannrpt.
    \19\ See pg. 58 of the CJR Model Third Annual Evaluation Report 
accessible at: https://innovation.cms.gov/data-and-reports/2020/cjr-thirdannrpt.
    \20\ 2017 Medicare Cost Report data accessible at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Downloadable-Public-Use-Files/Cost-Reports.
    \21\ Medicare Inpatient Claims data from January-December 2019, 
Chronic Conditions Warehouse.
---------------------------------------------------------------------------

    We received no comments on this section of the proposed rule and 
therefore are finalizing this section without modification.

G. Regulatory Review Costs

    If regulations impose administrative costs on private entities, 
such as the time needed to read and interpret this final rule, we 
should estimate the cost associated with regulatory review. Due to the 
uncertainty involved with accurately quantifying the number of entities 
that will review the rule, we assume that the total number providers 
participating in CJR, or 470 providers as of October 2019, would be the 
number of reviewers of this final rule. We acknowledge that this 
assumption may understate or overstate the costs of reviewing this 
rule. It is possible that some reviewers chose not to comment on the 
proposed rule. However, for the purposes of our estimate we assume that 
each reviewer reads approximately 100 percent of the rule.
    Using the wage information from the BLS for medical and health 
service managers (Code 11-9111), we estimate that the cost of reviewing 
this rule is $110.74 per hour, including overhead and fringe benefits 
https://www.bls.gov/oes/current/oes_nat.htm. Assuming an average 
reading speed, we estimate that it would take approximately 2.3 hours 
for staff to review this final rule. For each entity that reviews the 
rule, the estimated cost is $254.70 (2.3 hours x $110.74). Therefore, 
we estimate that the total cost of reviewing this regulation is 
$119,709 ($254.70 x 470 reviewers).

H. Accounting Statement

    As required by OMB Circular A-4 under Executive Order 12866 
(available at https://www.whitehouse.gov/sites/whitehouse.gov/files/omb/circulars/A4/a-4.pdf) in Table 9, we have prepared an accounting 
statement showing the classification of transfers, benefits, and costs 
associated with the provisions in this proposed rule. The accounting 
statement is based on estimates provided in this regulatory impact 
analysis. As described in Table 7, we estimate the proposed 3-year 
extension and changes to the CJR model will result in savings to the 
federal government of $269 million over the 3 performance years of the 
model from 2021 to 2023. The following Table 9 shows the annualized 
change in-- (1) net federal monetary transfers; and (2) potential 
reconciliation payments to participating hospitals net of repayments 
from participant hospitals that is associated

[[Page 23568]]

with the provisions of the proposed rule as compared to baseline. In 
Table 9, the annualized change in payments based on a 7 percent and 3 
percent discount rate, results in net federal monetary transfer from 
the participant IPPS hospitals to the federal government of $83 million 
and $86 million, respectively.
[GRAPHIC] [TIFF OMITTED] TR03MY21.019

    The updated accounting statement in this final rule is based on 
estimates provided in this regulatory impact analysis in this final 
rule. As described in Table 7a, we estimate the extension and changes 
to the CJR model will result in savings to the federal government of 
$217 million over the 3 performance years of the model from 2021 to 
2024. The following Table 9a in this final rule shows the annualized 
change in-- (1) net federal monetary transfers; and (2) potential 
reconciliation payments to participating hospitals net of repayments 
from participant hospitals that is associated with the provisions of 
this final rule as compared to baseline. In Table 9a in this final 
rule, the annualized change in payments based on a 7 percent and 3 
percent discount rate, results in net federal monetary transfer from 
the participant IPPS hospitals to the federal government of $59 million 
and $63 million, respectively.
[GRAPHIC] [TIFF OMITTED] TR03MY21.020

    Section 202 of the Unfunded Mandates Reform Act of 1995 also 
requires that agencies assess anticipated costs and benefits before 
issuing any rule whose mandates require spending in any one year of 
$100 million in 1995 dollars, updated annually for inflation. In 2021, 
that threshold is approximately $158 million. This rule will have no 
consequential effect on state, local, or tribal governments or on the 
private sector.
    Executive Order 13132 establishes certain requirements that an 
agency must meet when it promulgates a proposed rule (and subsequent 
final rule) that imposes substantial direct requirement costs on state 
and local governments, preempts state law, or otherwise has Federalism 
implications. Since this regulation does not impose any costs on state 
or local governments, the requirements of Executive Order 13132 are not 
applicable.

I. Analysis of Regulatory Alternatives

    As noted previously, Executive Orders 12866 and 13563 direct 
agencies to assess all costs and benefits of available regulatory 
alternatives. In developing the proposed rule, we considered a number 
of regulatory alternatives. These include--
     Broadening or modifying the types of entities that may 
convene an episode under the CJR model;
     Calculating coefficients separately for each region or 
applying risk-standardization to the regional target price prior to 
applying the beneficiary-specific risk score (as noted earlier in 
section II.C.4. of the proposed rule ``Additional Episode-Level Risk 
Adjustment''); and
     Utilizing the regional median episode costs as a basis for 
the market trend factor update calculation, rather than the regional 
mean episode costs for this calculation (as noted earlier in section 
II.C.6. of this final rule ``Changes to Trend Factor Calculation'')
    These regulatory alternatives and their potential costs and 
benefits are explored in more detail later in this section.
    In developing this final rule, as we believe it would be good for 
the CMS Innovation Center to consider a wider range of participants for 
future LEJR models, we considered broadening and modifying the types of 
entities that may initiate an episode under the CJR model. However, the 
CJR model as established in notice-and-comment rulemaking, limited 
participants to hospitals. As the impetus for proposing this extension 
was that the active model is currently showing promise in terms of 
reducing costs while maintaining quality and we wished to continue that 
momentum, we were limited by timing. Further, we would likely have 
needed to reconsider and broaden the geographic scope of the model were 
we to extend participant types since the original model geography was 
based on hospital specific criteria. Further, we believe that 
broadening and modifying who may

[[Page 23569]]

initiate an episode would unnecessarily complicate the evaluation and 
limit the generalizability of the results affecting the ability of this 
model being certified in the future. Therefore, we did not propose to 
include additional participants in the proposed CJR model extension but 
rather solicited comment in section II.J. of this final rule on how a 
future LEJR model that incorporated other entities in addition to 
hospitals might be structured.
    We received many comments related to future LEJR models and the 
incorporation of other entities in addition to hospitals. A summary of 
those comments can be found in section II.J. of this final rule.
    In developing our risk adjustment methodology approach, although we 
proposed to calculate coefficients at the national level, we also 
considered calculating coefficients separately for each region or 
applying risk-standardization to the regional target price prior to 
applying the beneficiary-specific risk score (as noted earlier in 
section II.C.4. of this final rule ``Additional Episode-Level Risk 
Adjustment''). As we believe regional differences in risk for CJR HCC 
count and age should already be accounted for via our region/MS-DRG 
pricing strategy we proposed the computationally less complex national 
approach although we sought comment on a regional calculation of 
coefficients.
    After consideration of the public comments we received, we are 
finalizing the proposed policy to calculate the risk adjustment 
coefficients at the national level without applying risk 
standardization to the regional target price prior to applying the 
beneficiary-specific risk score. A summary of those comments and our 
responses can be found in section II.C.4. of this final rule.
    Finally, in developing our methodology for the market trend factor 
update calculation, we considered utilizing the regional median episode 
costs as a basis for the market trend factor update calculation, as 
medians are generally recognized as the preferred measure of central 
tendency for data that is not normally distributed. However, we did not 
propose to use the median in the market trend factor update, as 
discussed in section II.C.6. of this final rule, because we determined 
using the mean only resulted in a small difference in effect (the trend 
factors calculated using means were 0.01 higher than trend factors 
calculated using medians), and using the mean could benefit participant 
hospitals (that is, increase target prices more compared to the 
median). Further, using the mean aligns the trend calculation with the 
methodology for deriving the target prices for the model, which also 
relies on the mean rather than the median.
    After consideration of the public comments we received, we are 
finalizing the proposed policy to calculate the market trend factor 
using the mean of episode costs instead of the median. A summary of 
comments received regarding this alternative policy and our responses 
can be found in section II.C.6. of this final rule.
    I, Elizabeth Richter, Acting Administrator of the Centers for 
Medicare & Medicaid Services, approved this document on April 23, 2021.

List of Subjects in 42 CFR Part 510

    Administrative Practice and Procedure, Health facilities, Health 
professions, Medicare, and Reporting and recordkeeping requirements.

    For the reasons set forth in the preamble, the Centers for Medicare 
& Medicaid Services amends 42 CFR chapter IV as set forth below:

PART 510--COMPREHENSIVE CARE FOR JOINT REPLACEMENT MODEL

0
1. The authority citation for part 510 is revised to read as follows:

    Authority:  42 U.S.C. 1302, 1315a, and 1395hh.


0
2. Section 510.2 is amended by:
0
a. Adding a definition for ``Age bracket risk adjustment factor'';
0
b. Revising the definition of ``Anchor hospitalization'';
0
c. Addng definitions for``Anchor procedure'', ``BPCI Advanced'', ``CJR 
HCC count risk adjustment factor'', and ``Dual-eligibility risk 
adjustment factor'';
0
d. Revising the definitions of ``Episode of care (or Episode)'' and 
``Net payment reconciliation amount (NPRA)'';
0
e. Adding the definitions for ``OPPS'' and ``OP THA/OP TKA'';
0
f. Revising the definitions of ``Participant hospital'', ``Performance 
Year'', ``Quality improvement points'', and ``Reconciliation payment''; 
and
0
g. Adding the definition for ``Reconciliation target price''.
    The additions and revisions read as follows:


Sec.  510.2  Definitions.

* * * * *
    Age bracket risk adjustment factor means the coefficient of risk 
associated with a patient's age bracket, calculated as described in 
Sec.  510.301(a)(1).
* * * * *
    Anchor hospitalization means the initial hospital stay upon 
admission for a lower extremity joint replacement, for which the 
institutional claim is billed through the IPPS. Anchor hospitalization 
also includes an inpatient hospital admission within 3 days after an 
outpatient Total Knee Arthroplasty (TKA) or Total Hip Arthroplasty 
(THA).
    Anchor procedure means a TKA or THA procedure that is permitted and 
paid for by Medicare when performed in a hospital outpatient department 
(HOPD) and billed through the OPPS, except when the beneficiary is 
admitted to an inpatient hospital stay within 3 days after the TKA or 
THA.
* * * * *
    BPCI Advanced stands for the Bundled Payments for Care Improvement 
Advanced Model.
* * * * *
    CJR-HCC condition count risk adjustment factor means the 
coefficient of risk associated with a patient's total number of CMS 
Hierarchical Condition Categories, calculated as described in Sec.  
510.301(a)(1).
* * * * *
    Dual-eligibility risk adjustment factor means the coefficient of 
risk associated with beneficiaries that are eligible for full Medicaid 
benefits or beneficiaries that are not eligible for full Medicaid 
benefits, calculated as described in Sec.  510.301(a)(1).
* * * * *
    Episode of care (or Episode) means all Medicare Part A and B items 
and services described in Sec.  510.200(b) (and excluding the items and 
services described in Sec.  510.200(d)) that are furnished to a 
beneficiary described in Sec.  510.205 during the time period that 
begins with the beneficiary's admission to an anchor hospitalization 
or, on or after July 4, 2021, the date of admission to an anchor 
hospitalization or the date of the anchor procedure, as applicable, and 
ends on the 90th day after the following, as applicable:
    (1) The date of discharge from the anchor hospitalization (with the 
day of discharge itself being counted as the first day of the 90-day 
post-discharge period); or
    (2) The date of service for the anchor procedure.
* * * * *
    Net payment reconciliation amount (NPRA) means the amount 
determined in accordance with Sec.  510.305(e) or (m).
* * * * *
    OPPS stands for the outpatient prospective payment system.
    OP THA/OP TKA means a total hip arthroplasty or total knee 
arthroplasty, respectively, for which the institutional

[[Page 23570]]

claim is billed by the hospital through the OPPS.
* * * * *
    Participant hospital means one of the following:
    (1) During performance years 1 and 2 of the CJR model and the 
period from January 1, 2018 to January 31, 2018 of performance year 3, 
a hospital (other than a hospital excepted under Sec.  510.100(b)) with 
a CCN primary address located in one of the geographic areas selected 
for participation in the CJR model in accordance with Sec.  510.105.
    (2) Between February 1, 2018 and September 30, 2021 a hospital 
(other than a hospital excepted under Sec.  510.100(b)) that is one of 
the following:
    (i) A hospital with a CCN primary address located in a mandatory 
MSA as of February 1, 2018 that is not a rural hospital or a low-volume 
hospital on that date.
    (ii) A hospital that is a rural hospital or low-volume hospital 
with a CCN primary address located in a mandatory MSA that makes an 
election to participate in the CJR model in accordance with Sec.  
510.115.
    (iii) A hospital with a CCN primary address located in a voluntary 
MSA that makes an election to participate in the CJR model in 
accordance with Sec.  510.115.
    (3) Beginning October 1, 2021, a hospital that is not a rural 
hospital or a low-volume hospital as defined in Sec.  510.2, as of July 
4, 2021 (based on the date of the CMS notification letter and not the 
effective date of the rural reclassification, if applicable) with a CCN 
primary address located in a mandatory MSA.
* * * * *
    Performance year means one of the years in which the CJR model is 
being tested. Performance years for the model correlate to calendar 
years with the exceptions of performance year 1, which is April 1, 2016 
through December 31, 2016, performance year 5, which is January 1, 2020 
through September 30, 2021, and performance year 6 which is October 1, 
2021 through December 31, 2022. For reconciliation purposes, 
performance year 5 is divided into two subsets, performance year subset 
5.1 (January 1, 2020 through December 31, 2020) and performance year 
subset 5.2 (January 1, 2021 through September 30, 2021).
* * * * *
    Quality improvement points are points that CMS adds to a 
participant hospital's composite quality score for a measure if the 
hospital's performance percentile on an individual quality measure for 
performance years 2 through 4 and 6 through 8, or for performance year 
subsets of performance year 5, increases from the previous performance 
year or performance year subset by at least 2 deciles on the 
performance percentile scale, as described in Sec.  510.315(d). For 
performance year 1, CMS adds quality improvement points to a 
participant hospital's composite quality score for a measure if the 
hospital's performance percentile on an individual quality measure 
increases from the corresponding time period in the previous year by at 
least 2 deciles on the performance percentile scale, as described in 
Sec.  510.315(d).
* * * * *
    Reconciliation payment means a payment made by CMS to a CJR 
participant hospital as determined in accordance with Sec.  510.305(f) 
or (l).
* * * * *
    Reconciliation target price means, for performance years 6 through 
8, the target price applied to an episode at reconciliation, as 
determined in accordance with Sec.  510.301.
* * * * *

0
3. Section 510.100 is amended by revising paragraph (a) to read as 
follows:


Sec.  510.100  Episodes being tested.

    (a) Initiation of an episode. An episode is initiated when, with 
respect to a beneficiary described in Sec.  510.205--
    (1) The participant hospital admits the beneficiary for an anchor 
hospitalization; or
    (2) On or after July 4, 2021, an anchor procedure is performed at 
the participant hospital.
* * * * *

0
4. Section 510.105 is amended by adding paragraph (a)(3) to read as 
follows:


Sec.  510.105  Geographic areas.

    (a) * * *
    (3) Beginning with performance year 6, only the 34 MSAs designated 
as mandatory participation MSAs as of performance year 3.
* * * * *

0
5. Section 510.120 is amended by revising paragraph (a) introductory 
text to read as follows:


Sec.  510.120  CJR participant hospital CEHRT track requirements.

    (a) CJR CEHRT use. For performance years 2 through 8, CJR 
participant hospitals choose either of the following:
* * * * *

0
6. Section 510.200 is amended by--
0
a. Revising paragraph (a);
0
b. Adding paragraph (b)(15);
0
c. Revising paragraph (c);
0
d. Revising paragraphs (d)(4) introductory text, and (d)(6);
0
e. Adding paragraph (d)(7)
0
f. Revising paragraphs (e)(2), (e)(3) introductory text, and (e)(4) 
introductory text; and
0
g. Adding paragraph (e)(5).
    The revisions and additions read as follows:


Sec.  510.200  Time periods, included and excluded services, and 
attribution.

    (a) Time periods. All episodes must begin on or after April 1, 2016 
and end on or before December 31, 2024.
    (b) * * *
    (15) The surgeon's Part B claim for the LEJR procedure dated within 
the 3 days prior to an inpatient admission, if the LEJR procedure was 
performed at the participant hospital on an outpatient basis but the 
patient was subsequently admitted as an inpatient, resulting in an 
anchor hospitalization.
    (c) Episode attribution. All items and services included in the 
episode are attributed to the participant hospital at which the anchor 
hospitalization or anchor procedure, as applicable, occurs.
    (d) * * *
    (4) Items and services unrelated to the anchor hospitalization or 
the anchor procedure. Excluded services include, but are not limited, 
to the following:
* * * * *
    (6) For performance years 1 through 4 and for performance year 
subsets 5.1 and 5.2, payments for otherwise included items and services 
in excess of 2 standard deviations above the mean regional episode 
payment in accordance with Sec.  510.300(b)(5).
    (7) For performance years 6 through 8 only, payments for otherwise 
included items and services in excess of the 99th percentile of 
regional spending, ranked within each region, for each of the four MS-
DRG target price categories, as specified in Sec.  510.300(a)(1) and 
(6), for performance years 6 through 8, in accordance with Sec.  
510.300(b)(5).
* * * * *
    (e) * * *
    (2) For performance years 1 through 5 only, on an annual basis, or 
more frequently as needed, CMS updates the list of excluded services to 
reflect annual coding changes or other issues brought to CMS' 
attention.
    (3) For performance years 1 through 5 only, CMS applies the 
following standards when revising the list of excluded services for 
reasons other than to reflect annual coding changes:
* * * * *

[[Page 23571]]

    (4) For performance years 1 through 5 only, CMS posts the following 
to the CMS website:
* * * * *
    (5) For performance years 6 through 8, the list of excluded 
services posted on the CMS website as it appears at the beginning of 
performance year 5 will apply and will not be updated.

0
7. Section 510.205 is amended by revising paragraph (a)(6)(iii) to read 
as follows:


 Sec.  510.205  Beneficiary inclusion criteria.

    (a) * * *
    (6) * * *
    (iii) A Shared Savings Program ACO in the ENHANCED track (formerly 
Track 3).
* * * * *

0
8. Section 510.210 is amended by revising paragraphs (a) and (b)(1)(ii) 
to read as follows:


 Sec.  510.210  Determination of the episode.

    (a) General. (1) An episode begins with the admission of a Medicare 
beneficiary described in Sec.  510.205 to a participant hospital for an 
anchor hospitalization and ends on the 90th day after the date of 
discharge, with the day of discharge itself being counted as the first 
day in the 90-day post-discharge period.
    (2) On or after July 4, 2021, an episode--
    (i) Begins and ends in the manner specified in paragraph (a)(1) of 
this section; or
    (ii) Begins on the date of service of an anchor procedure furnished 
to a Medicare beneficiary described in Sec.  510.205 and ends on the 
90th day after the date of service of the anchor procedure.
    (b) * * *
    (1) * * *
    (ii) Is readmitted to any participant hospital for another anchor 
hospitalization, or, on or after July 4, 2021, receives an anchor 
procedure at any participant hospital.
* * * * *

0
9. Section 510.300 is amended by--
0
a. Revising paragraph (a)(2) through (a)(4);
0
b. Adding paragraphs (a)(6), and (b)(1)(iv) through (vi); and
0
c. Revising paragraphs (b)(2)(iii), (b)(5), and (c)(3)(iii).
    The revisions and additions read as follows:


Sec.  510.300  Determination of episode quality-adjusted target prices.

    (a) * * *
    (2) Applicable time period for performance year or performance year 
subset episode quality-adjusted target prices. For performance years 1 
through 4 and performance year subset 5.1 only, episode quality-
adjusted target prices are updated to account for Medicare payment 
updates no less than 2 times per year, for updated quality-adjusted 
target prices effective October 1 and January 1, and at other intervals 
if necessary.
    (3) Episodes that straddle performance years, performance year 
subsets, or payment updates. The quality-adjusted target price that 
applies to the episode is one of the following:
    (i) For episodes beginning on or after April 1, 2016 and ending on 
or before September 30, 2021, the date of admission for the anchor 
hospitalization.
    (ii) For episodes beginning on or after July 4, 2021 and ending on 
or after October 1, 2021, the date of the anchor procedure or the date 
of admission for the anchor hospitalization, as applicable.
    (4) Identifying episodes with hip fracture. CMS develops a list of 
ICD-CM hip fracture diagnosis codes that, when reported in the 
principal diagnosis code files on the claim for the anchor 
hospitalization or anchor procedure, represent a bone fracture for 
which a hip replacement procedure, either a partial hip arthroplasty or 
a total hip arthroplasty, could be the primary surgical treatment. The 
list of ICD-CM hip fracture diagnosis codes used to identify hip 
fracture episodes can be found on the CMS website. Beginning on October 
1, 2020, hip fracture episodes initiated by an anchor hospitalization 
will be identified by MS-DRGs 521 and 522.
    (i) For performance years 1 through 5 only, on an annual basis, or 
more frequently as needed, CMS updates the list of ICD-CM hip fracture 
diagnosis codes to reflect coding changes or other issues brought to 
CMS' attention.
    (ii) For performance years 1 through 5 only, CMS applies the 
following standards when revising the list of ICD-CM hip fracture 
diagnosis codes.
    (A) The ICD-CM diagnosis code is sufficiently specific that it 
represents a bone fracture for which a physician could determine that a 
hip replacement procedure, either a Partial Hip Arthroplasty (PHA) or a 
THA, could be the primary surgical treatment.
    (B) The ICD-CM diagnosis code is the primary reason (that is, 
principal diagnosis code) for the anchor hospitalization.
    (iii) For performance years 1 through 5 only, CMS posts the 
following to the CMS website:
    (A) Potential ICD-CM hip fracture diagnosis codes for public 
comment; and
    (B) A final ICD-CM hip fracture diagnosis code list after 
consideration of public comment.
    (iv) For performance years 6 through 8, the hip fracture diagnosis 
code list posted at https://innovation.cms.gov/Files/worksheets/cjr-icd10hipfracturecodes.xlsx as it appears at the beginning of 
performance year 5 will not be updated. The hip fracture diagnosis code 
list will be used to identify hip fracture episodes initiated by an 
anchor procedure in performance years 6 through 8.
* * * * *
    (6) For episodes beginning on or after July 4, 2021 that are 
initiated by an anchor procedure, permitted OP TKAs and OP THAs are 
grouped with MS-DRG 470 or MS-DRG 522 episodes as follows:
    (i) Permitted OP THAs with hip fracture group with MS-DRG 522.
    (ii) Permitted OP THAs without hip fracture and permitted OP TKAs 
group with MS-DRG 470.
    (b) * * *
    (1) * * *
    (iv) Episodes beginning in 2019 for performance year 6.
    (v) Episodes beginning in 2021 for performance year 7.
    (vi) Episodes beginning in 2022 for performance year 8.
    (2) * * *
    (iii) Regional historical episode payments for performance year 4, 
for each subset of performance year 5, and performance years 6 through 
8.
* * * * *
    (5) Exception for high episode spending. (i) For performance years 
1 through 4, and for performance year 5, each subset thereof, episode 
payments are capped at 2 standard deviations above the mean regional 
episode payment for both the hospital-specific and regional components 
of the quality-adjusted target price.
    (ii) For performance years 6 through 8, episode payments are capped 
at the 99th percentile of regional spending for each of the four MS-DRG 
categories, as specified in Sec.  510.300(a)(1) and (6).
* * * * *
    (c) * * *
    (3) * * *
    (iii) In performance years 4, each subset of performance year 5, 
and performance years 6 through 8, 3.0 percent.
* * * * *

0
10. Section 510.301 is added to read as follows:

[[Page 23572]]

Sec.  510.301  Determination of reconciliation target prices.

    Beginning with performance year 6, the quality-adjusted target 
price computed under Sec.  510.300 is further adjusted for risk and 
market trends as described in this section to arrive at the 
reconciliation target price amount, with the exception of episodes that 
are reconciled in performance year 6 but subject to a performance year 
subset 5.2 target price. Specifically:
    (a) Risk adjustment. (1) The quality-adjusted target prices 
computed under Sec.  510.300 are risk adjusted at a beneficiary level 
by a CJR HCC count risk adjustment factor, an age bracket risk 
adjustment factor, and a dual-eligibility status risk adjustment 
factor. All three factors are binary, yes/no variables, meaning that a 
beneficiary either does or does not meet the criteria for a specific 
variable.
    (i) The CJR HCC count risk adjustment factor uses five variables, 
representing beneficiaries with zero, one, two, three, or four or more 
CMS-HCC conditions.
    (ii) The age bracket risk adjustment factor uses four variables, 
representing beneficiaries aged--
    (A) Less than 65 years;
    (B) 65 to 74 years;
    (C) 75 years to 84 years; or
    (D) 85 years or more.
    (iii) The dual-eligibility status factor uses two variables, 
representing beneficiaries that are eligible for full Medicaid benefits 
or beneficiaries that are not eligible for full Medicaid benefits.
    (2) All three factors are computed prior to the start of 
performance years 6 and 8 via a linear regression analysis. The 
regression analysis is computed using 1 year of claims data as follows:
    (i) For performance year 6, CMS uses claims data with dates of 
service dated January 1, 2019 to December 31, 2019.
    (ii) For performance year 7, CMS uses the same regression analysis 
results and corresponding coefficients that were calculated for 
performance year 6.
    (iii) For performance year 8, CMS uses claims data with dates of 
service dated January 1, 2021 to December 31, 2021.
    (3)(i) The dependent variable in the annual regression that 
produces the risk adjustment coefficients is equal to the difference 
between the log transformed target price calculated under Sec.  510.300 
and the capped episode costs as described in Sec.  510.300(b)(5)(ii).
    (ii) The independent variables are binary values assigned to each 
CJR HCC count variable, age bracket variable and dual-eligibility 
status variable.
    (iii) Using these variables, the annual regression produces 
exponentiated coefficients to determine the anticipated marginal effect 
of each risk adjustment factor on episode costs. CMS transforms, or 
exponentiate, these coefficients in order to ``reverse'' the previous 
logarithmic transformation, and the resulting coefficients are the CJR 
HCC count risk adjustment factor, the age bracket risk adjustment 
factor, and the dual-eligibility status factor that would be used 
during reconciliation for the subsequent performance year.
    (4)(i) At the time of reconciliation, the quality adjusted target 
prices computed under Sec.  510.300 are risk adjusted at the 
beneficiary level by applying the applicable CJR HCC count risk 
adjustment factor, the age bracket risk adjustment factor, and the 
dual-eligibility risk adjustment factor specific to the beneficiary in 
the episode.
    (ii)(A) For the CJR HCC count risk adjustment factor, applicable 
means the coefficient that applies to the CMS-HCC condition count for 
the beneficiary in the episode;
    (B) For the age bracket risk adjustment factor, applicable means 
the coefficient for the age bracket into which the beneficiary falls on 
the first day of the episode; and
    (C) For the dual-eligibility risk adjustment factor, applicable 
means the coefficient for beneficiaries that are eligible for full 
Medicaid benefits on the first day of the episode.
    (5)(i) The risk-adjusted target prices are normalized at 
reconciliation to remove the overall impact of adjusting for age, CJR 
HCC count, and dual-eligibility status on the national average target 
price.
    (ii) The normalization factor is the national mean of the target 
price for all episode types divided by the national mean of the risk-
adjusted target price.
    (iii) CMS applies the normalization factor to the previously 
calculated, beneficiary-level, risk-adjusted target prices specific to 
each episode region and MS-DRG combination (as specified in paragraph 
(a)(4) of this section).
    (iv) These normalized target prices are then further adjusted for 
market trends (as specified in paragraph (b) of this section) and 
quality performance (as specified at Sec.  510.300) to become the 
reconciliation target prices, which are compared to actual episode 
costs at reconciliation, as specified in Sec.  510.305(m)(1)(i).
    (b) Market trend adjustment factor. (1) The risk-adjusted quality-
adjusted target price computed under Sec.  510.300 and paragraph (a) of 
this section is further adjusted for market trend changes at the region 
and MS-DRG level.
    (2) This adjustment is accomplished by multiplying each risk-
adjusted quality-adjusted target price computed under Sec.  510.300 and 
paragraph (a) of this section by the applicable market trend adjustment 
factor.
    (3) The applicable market trend adjustment factor is calculated as 
the percent difference between the average regional MS-DRG episode 
costs computed using the performance year claims data and comparison 
average regional MS-DRG fracture episode costs computed using 
historical calendar year claims data used to calculate the regional 
target prices in effect for that performance year.

0
11. Section 510.305 is amended by--
0
a. Revising paragraphs (b), (d) heading, and (e) introductory text;
0
b. Adding paragraphs (f)(1)(iv) through (vi);
0
c. Revising paragraph (i); and
0
d. Adding paragraphs (l) and (m).
    The revisions and additions read as follows:


Sec.  510.305  Determination of the NPRA and reconciliation process.

* * * * *
    (b) Reconciliation. (1) For performance years 1 through 4 and for 
each subset of performance year 5, CMS uses a series of reconciliation 
processes, which CMS performs as described in paragraphs (d) and (f) of 
this section after the end of each performance year, to establish final 
payment amounts to participant hospitals for CJR model episodes for a 
given performance year.
    (2) For performance years 6 through 8, CMS conducts one 
reconciliation process, which CMS performs as described in paragraphs 
(l) and (m) of this section after the end of each performance year, to 
establish final payment amounts to participant hospitals for CJR model 
episodes for a given performance year.
    (3) Following the end of each performance year, for performance 
years 1 through 4 and for performance year 5, each subset thereof, CMS 
determines actual episode payments for each episode for the performance 
year (other than episodes that have been canceled in accordance with 
Sec.  510.210(b)) and determines the amount of a reconciliation payment 
or repayment amount.
* * * * *
    (d) Annual reconciliation for performance years 1 through 5.
* * * * *
    (e) Calculation of the NPRA for performance years 1 through 5. By 
comparing the quality-adjusted target prices described in Sec.  510.300 
and the participant hospital's actual episode spending for each of 
performance years 1 through 4, and for performance year

[[Page 23573]]

5, each subset thereof, and applying the adjustments in paragraph 
(e)(1)(v) of this section, CMS establishes an NPRA for each participant 
hospital for each of performance years 1 through 4 and for performance 
year 5, each subset thereof.
* * * * *
    (f) * * *
    (1) * * *
    (iv) Results from the performance year 6 reconciliation and post-
episode spending calculations as described in paragraph (m) of this 
section are added together in order to determine the reconciliation 
payment or repayment amount for performance year 6.
    (v) Results from the performance year 7 reconciliation and post-
episode spending calculations as described in paragraph (m) of this 
section are added together in order to determine the reconciliation 
payment or repayment amount for performance year 7.
    (vi) Results from the performance year 8 reconciliation and post-
episode spending calculations as described in paragraph (m) of this 
section are added together in order to determine the reconciliation 
payment or repayment amount for performance year 8.
* * * * *
    (l) Annual reconciliation for performance years 6 through 8. (1) 
Beginning 6 months after the end of each of performance years 6 through 
8, CMS does all of the following:
    (i) Performs a reconciliation calculation to establish an NPRA for 
each participant hospital.
    (ii) For participant hospitals that experience a reorganization 
event in which one or more hospitals reorganize under the CCN of a 
participant hospital, performs--
    (A) Separate reconciliation calculations for each predecessor 
participant hospital for episodes where the anchor hospitalization 
admission or the anchor procedure occurred before the effective date of 
the reorganization event; and
    (B) Reconciliation calculations for each new or surviving 
participant hospital for episodes where the anchor hospitalization 
admission or anchor procedure occurred on or after the effective date 
of the reorganization event.
    (2) CMS--
    (i) Calculates the NPRA for each participant hospital in accordance 
with paragraph (m) of this section including the adjustments provided 
for in paragraph (m)(1)(vii) of this section; and
    (ii) Assesses whether participant hospitals meet specified quality 
requirements under Sec.  510.315.
    (m) Calculation of the NPRA for performance years 6 through 8. By 
comparing the reconciliation target prices described in Sec.  510.301 
and the participant hospital's actual episode spending for the 
performance year and applying the adjustments in paragraph (m)(1)(vii) 
of this section, CMS establishes an NPRA for each participant hospital 
for each of performance years 6 through 8.
    (1) In calculating the NPRA for each participant hospital for each 
performance year, CMS does the following:
    (i) Determines actual episode payments for each episode included in 
the performance year (other than episodes that have been canceled in 
accordance with Sec.  510.210(b)) using claims data that is available 6 
months after the end of the performance year. Actual episode payments 
are capped at the amount determined in accordance with Sec.  
510.300(b)(5)(ii) for the performance year, the amount determined in 
paragraph (k) of this section for episodes affected by extreme and 
uncontrollable circumstances, or the target price determined for that 
episode under Sec.  510.300 for episodes that contain a COVID-19 
Diagnosis Code as defined in Sec.  510.2.
    (ii) Multiplies each episode reconciliation target price by the 
number of episodes included in the performance year (other than 
episodes that have been canceled in accordance with Sec.  510.210(b)) 
to which that episode reconciliation target price applies.
    (iii) Aggregates the amounts computed in paragraph (m)(1)(ii) of 
this section for all episodes included in the performance year (other 
than episodes that have been canceled in accordance with Sec.  
510.210(b)).
    (iv) Subtracts the amount determined under paragraph (m)(1)(i) of 
this section from the amount determined under paragraph (m)(1)(iii) of 
this section.
    (v) Performs an additional calculation using claims data available 
at that time, to account for any episode cancelations due to overlap 
between the CJR model and other CMS models and programs, or for other 
reasons as specified in Sec.  510.210(b).
    (vi) Conducts a post-episode spending calculation as follows: If 
the average post-episode Medicare Parts A and B payments for a 
participant hospital in the performance year being reconciled is 
greater than 3 standard deviations above the regional average post-
episode payments for that same performance year, then the spending 
amount exceeding 3 standard deviations above the regional average post-
episode payments for the same performance year is subtracted from the 
net reconciliation or added to the repayment for that performance year.
    (vii) Applies the following prior to determination of the 
reconciliation payment or repayment amount:
    (A) Limitation on loss. Except as provided in paragraph 
(m)(1)(vii)(C) of this section, the total amount of the NPRA for a 
performance year cannot exceed 20 percent of the amount calculated in 
paragraph (m)(1)(iii) of this section for the performance year. The 
post-episode spending calculation amount in paragraph (m)(vi) of this 
section is not subject to the limitation on loss.
    (B) Limitation on gain. The total amount of the NPRA for a 
performance year cannot exceed 20 percent of the amount calculated in 
paragraph (m)(1)(iii) of this section for the performance year. The 
post-episode spending calculation amount in paragraph (m)(vi) of this 
section are not subject to the limitation on gain.
    (C) Limitation on loss for certain providers. Financial loss limits 
for rural hospitals, SCHs, MDHs, and RRCs for performance years 6 
through 8. If a participant hospital is a rural hospital, SCH, MDH, or 
RRC, the amount cannot exceed 5 percent of the amount calculated in 
paragraph (m)(1)(iii) of this section.
    (2) [Reserved]
* * * * *

0
12. Section 510.310 is amended by--
0
a. Removing paragraph (b)(4)(i);
0
b. Redesignating paragraphs (b)(4)(ii), (iii), and (iv) as paragraphs 
(b)(4)(i), (ii), and (iii);
0
c. Revising newly redesignated paragraph (b)(4)(iii);
0
d. Removing paragraph (b)(5);
0
e. Redesignating paragraph (b)(6) and (7) as paragraph (b)(5) and (6); 
and
0
f. Revising newly redesignated paragraph (b)(6).
    The revisions read as follows:


Sec.  510.310  Appeals process.

* * * * *
    (b) * * *
    (4) * * *
    (iii) The procedures (including format and deadlines) for 
submission of briefs and evidence.
* * * * *
    (6) The CMS reconsideration official makes all reasonable efforts 
to issue a written determination within 30 days of the deadline for 
submission of briefs and evidence. The determination is final and 
binding.
* * * * *

0
13. Section 510.315 is amended by revising paragraphs (d), (f)(1), and 
(f)(2) to read as follows:

[[Page 23574]]

Sec.  510.315  Composite quality scores for determining reconciliation 
payment eligibility and quality incentive payments.

* * * * *
    (d) Quality improvement points. (1) For performance year 1, if a 
participant hospital's quality performance percentile on an individual 
measure described in Sec.  510.400(a) increases from the corresponding 
time period in the previous year by at least 2 deciles on the 
performance percentile scale, then the hospitals is eligible to receive 
quality improvement points equal to 10 percent of the total available 
point for that individual measure up to a maximum composite quality 
score of 20 points.
    (2) For each of performance years 2 through 4, each of performance 
year subsets 5.1 and 5.2, and each of performance years 6 through 8, if 
a participant hospital's quality performance percentile on an 
individual measure described in Sec.  510.400(a) increases from the 
previous performance year or performance year subset by at least 2 
deciles on the performance percentile scale, then the hospital is 
eligible to receive quality improvement points equal to 10 percent of 
the total available point for that individual measure up to a maximum 
composite quality score of 20 points.
* * * * *
    (f) * * *
    (1) Performance years 1 through 5. For performance years 1 through 
5--
    (i) A 1.0 percentage point reduction to the effective discount 
factor or applicable discount factor for participant hospitals with 
good quality performance, defined as composite quality scores that are 
greater than or equal to 6.9 and less than or equal to 15.0; or
    (ii) A 1.5 percentage point reduction to the effective discount 
factor or applicable discount factor for participant hospitals with 
excellent quality performance, defined as composite quality scores that 
are greater than 15.0.
    (2) Performance years 6 through 8. For performance years 6 through 
8--
    (i) A 1.5-percentage point reduction to the effective discount 
factor or applicable discount factor for participant hospitals with 
good quality performance, defined as composite quality scores that are 
greater than or equal to 6.9 and less than or equal to 15.0; or
    (ii) A 3-percentage point reduction to the effective discount 
factor or applicable discount factor for participant hospitals with 
excellent quality performance, defined as composite quality scores that 
are greater than 15.0.
* * * * *

0
14. Section 510.400 is amended--
0
a. In paragraph (b)(2)(i) by removing the phrase ``over the 5 years'' 
and adding in its place the phrase ``over the first 5 years'';
0
b. In paragraph (b)(2)(ii) introductory text by removing the phrase 
``of the program'' and adding in its place the phrase ``of the model''; 
and
0
c. By adding paragraph (b)(4).
    The addition reads as follows:


Sec.  510.400  Quality measures and reporting.

* * * * *
    (b) * * *
    (4) For years 6 through 8 of the model the following data are 
requested by CMS for each performance period as follows:
    (i) Year 6 (October 1, 2021 to December 31, 2022). Submit--
    (A) Post-operative data on primary elective THA/TKA procedures for 
>=80% or >=200 procedures performed between July 1, 2019 and June 30, 
2020; and
    (B) Pre-operative data on primary elective THA/TKA procedures for 
>=80% or >=300 procedures performed between July 1, 2021 and June 30, 
2022.
    (ii) Year 7 (2023). Submit--
    (A) Post-operative data on primary elective THA/TKA procedures for 
80% or 300 procedures performed between July 1, 2021 
and June 30, 2022; and
    (B) Pre-operative data on primary elective THA/TKA procedures for 
>=85% or >=400 procedures performed between July 1, 2022 and June 30, 
2023.
    (iii) Year 8 (2024). Submit--
    (A) Post-operative data on primary elective THA/TKA procedures for 
>=85% or >=400 procedures performed between July 1, 2022 and June 30, 
2023; and
    (B) Pre-operative data on primary elective THA/TKA procedures for 
>=90% or >=500 procedures performed between July 1, 2023 and June 30, 
2024.
* * * * *

0
15. Section 510.405 is amended by revising paragraphs (b)(1) and (3) to 
read as follows:


Sec.  510.405  Beneficiary choice and beneficiary notification.

* * * * *
    (b) * * *
    (1) Participant hospital beneficiary notification--(i) Notification 
to beneficiaries. Each participant hospital must provide written 
notification to any Medicare beneficiary that meets the criteria in 
Sec.  510.205 of his or her inclusion in the CJR model.
    (ii) Timing of notification. Prior to discharge from the anchor 
hospitalization, or prior to discharge from the anchor procedure, as 
applicable, the participant hospital must provide the CJR beneficiary 
with a participant hospital beneficiary notification as described in 
paragraph (b)(1)(iv) of this section.
    (iii) List of beneficaries receiving a notification. The 
participant hospital must be able to generate a list of all 
beneficiaries receiving such notification, including the date on which 
the notification was provided to the beneficiary, to CMS or its 
designee upon request.
    (iv) Content of notification. The beneficiary notification must 
contain all of the following:
    (A) A detailed explanation of the model and how it might be 
expected to affect the beneficiary's care.
    (B) Notification that the beneficiary retains freedom of choice to 
choose providers and services.
    (C) Explanation of how patients can access care records and claims 
data through an available patient portal, and how they can share access 
to their Blue Button[supreg] electronic health information with 
caregivers.
    (D) A statement that all existing Medicare beneficiary protections 
continue to be available to the beneficiary. These include the ability 
to report concerns of substandard care to Quality Improvement 
Organizations or the 1-800-MEDICARE helpline.
    (E) A list of the providers, suppliers, and ACOs with whom the CJR 
participant hospital has a sharing arrangement. This requirement may be 
fulfilled by the participant hospital including in the detailed 
notification a Web address where beneficiaries may access the list.
* * * * *
    (3) Discharge planning notice. A participant hospital must provide 
the beneficiary with a written notice of any potential financial 
liability associated with non-covered services recommended or presented 
as an option as part of discharge planning, no later than the time that 
the beneficiary discusses a particular post-acute care option or at the 
time the beneficiary is discharged from an anchor procedure or anchor 
hospitalization, whichever occurs earlier.
    (i) If the participant hospital knows or should have known that the 
beneficiary is considering or has decided to receive a non-covered 
post-acute care service or other non-covered associated service or 
supply, the participant hospital must notify the beneficiary that the 
service would not be covered by Medicare.
    (ii) If the participant hospital is discharging a beneficiary to a 
SNF prior

[[Page 23575]]

to the occurrence of a 3-day hospital stay, and the beneficiary is 
being transferred to or is considering a SNF that would not qualify 
under the SNF 3-day waiver in Sec.  510.610, the participant hospital 
must notify the beneficiary in accordance with paragraph (b)(3)(i) of 
this section that the beneficiary will be responsible for payment for 
the services furnished by the SNF during that stay, except those 
services that would be covered by Medicare Part B during a non-covered 
inpatient SNF stay.
* * * * *

0
16. Section 510.500 is amended by revising paragraphs (c)(4)(i) and 
(ii) to read as follows:


Sec.  510.500  Sharing arrangements under the CJR model.

* * * * *
    (c) * * *
    (4) * * *
    (i) For episodes beginning on or after April 1, 2016 and ending on 
or before September 30, 2021, in the case of a CJR collaborator who is 
a physician or non-physician practitioner, 50 percent of the Medicare-
approved amounts under the PFS for items and services furnished by that 
physician or non-physician practitioner to the participant hospital's 
CJR beneficiaries during CJR model episodes that occurred during the 
same performance year for which the participant hospital accrued the 
internal cost savings or earned the reconciliation payment that 
comprises the gainsharing payment being made.
    (ii) For episodes beginning on or after April 1, 2016 and ending on 
or before September 30, 2021, in the case of a CJR collaborator that is 
a PGP or NPPGP, 50 percent of the Medicare-approved amounts under the 
PFS for items and services billed by that PGP or NPPGP and furnished to 
the participant hospital's CJR beneficiaries by the PGP members or 
NPPGP members respectively during CJR model episodes that occurred 
during the same performance year for which the participant hospital 
accrued the internal cost savings or earned the reconciliation payment 
that comprises the gainsharing payment being made.
* * * * *

0
17. Section 510.505 is amended by revising paragraphs (b)(8)(i) and 
(ii) to read as follows:


Sec.  510.505  Distribution arrangements.

* * * * *
    (b) * * *
    (8) * * *
    (i) For episodes beginning on or after April 1, 2016 and ending on 
or before September 30, 2021, in the case of a collaboration agent that 
is a physician or non-physician practitioner, 50 percent of the total 
Medicare-approved amounts under the PFS for items and services 
furnished by the collaboration agent to the participant hospital's CJR 
beneficiaries during CJR model episodes that occurred during the same 
performance year for which the participant hospital accrued the 
internal cost savings or earned the reconciliation payment that 
comprises the gainsharing payment being distributed.
    (ii) For episodes beginning on or after April 1, 2016 and ending on 
or before September 30, 2021, in the case of a collaboration agent that 
is a PGP or NPPGP, 50 percent of the total Medicare-approved amounts 
under the PFS for items and services billed by that PGP or NPPGP for 
items and services furnished by PGP members or NPPGP member 
respectively to the participant hospital's CJR beneficiaries during CJR 
model episodes that occurred during the same performance year for which 
the participant hospital accrued the internal cost savings or earned 
the reconciliation payment that comprises the gainsharing payment being 
distributed.
* * * * *

0
18. Section 510.506 is amended by revising paragraph (b)(8) to read as 
follows:


Sec.  510.506  Downstream distribution arrangements.

* * * * *
    (b) * * *
    (8) Except for a downstream distribution payment from a PGP to a 
PGP member that complies with Sec.  411.352(g) of this chapter, for 
episodes beginning on or after April 1, 2016 and ending on or before 
September 30, 2021 the total amount of downstream distribution payments 
for a performance year paid to a downstream collaboration agent who is 
a physician or non-physician practitioner and is either a member of a 
PGP or a member of an NPPGP must not exceed 50 percent of the total 
Medicare-approved amounts under the PFS for items and services 
furnished by the downstream collaboration agent to the participant 
hospital's CJR beneficiaries during a CJR model episode that occurred 
during the same performance year for which the participant hospital 
accrued the internal cost savings or earned the reconciliation payment 
that comprises the distribution payment being distributed.
* * * * *


Sec.  510.600  [Amended]

0
19. Section 510.600 is amended in paragraph (b)(1) by removing the 
phrase ``an anchor hospitalization'' and adding in its place the phrase 
``an anchor hospitalization or anchor procedure.''

0
20. Section 510.610 is amended--
0
a. By revising paragraph (a); and
0
b. In paragraph (b)(1), removing the phrase ``qualifying inpatient 
stay.'' and adding in its place the phrase ``qualifying inpatient stay 
or anchor procedure.''
    The revision reads as follows:


Sec.  510.610  Waiver of SNF 3-day rule.

    (a) Waiver of the SNF 3-day rule--(1) Performance year--(i) 
Performance years 2 through 5. For episodes being tested in performance 
years 2 through 5 of the CJR model, CMS waives the SNF 3-day rule for 
coverage of a SNF stay for a beneficiary who is a CJR beneficiary on 
the date of discharge from the anchor hospitalization, but only if the 
SNF is identified on the applicable calendar quarter list of qualified 
SNFs at the time of the CJR beneficiary's admission to the SNF.
    (ii) Performance years 6 through 8. (A) For episodes being tested 
in performance years 6 through 8 of the CJR model, CMS waives the SNF 
3-day rule for coverage of a SNF stay within 30 days of the date of 
discharge from the anchor hospitalization for a beneficiary who is a 
CJR beneficiary on the date of discharge from the anchor 
hospitalization, but only if the SNF is identified on the applicable 
calendar quarter list of qualified SNFs at the time of the CJR 
beneficiary's admission to the SNF.
    (B) For episodes being tested in performance years 6 through 8 of 
the CJR model, CMS waives the SNF 3-day rule for coverage of a SNF stay 
within 30 days of the date of service of the anchor procedure for a 
beneficiary who is a CJR beneficiary on the date of service of the 
anchor procedure, but only if the SNF is identified on the applicable 
calendar quarter list of qualified SNFs at the time of the CJR 
beneficiary's admission to the SNF.

[[Page 23576]]

    (2) Determination of qualified SNFs. CMS determines the qualified 
SNFs for each calendar quarter based on a review of the most recent 
rolling 12 months of overall star ratings on the Five-Star Quality 
Rating System for SNFs on the Nursing Home Compare website. Qualified 
SNFs are rated an overall of 3 stars or better for at least 7 of the 12 
months.
    (3) Posting of qualified SNFs. CMS posts to the CMS website the 
list of qualified SNFs in advance of the calendar quarter.
* * * * *

    Dated: April 27, 2021.
Xavier Becerra,
Secretary, Department of Health and Human Services.
[FR Doc. 2021-09097 Filed 4-29-21; 4:15 pm]
BILLING CODE 4120-01-P