CMS Joint Replacement Rules Debated, Comment Period Extended

Laura Arenschield

April 29, 2020

Proposed revisions to the Centers for Medicare and Medicaid Services (CMS) rules for joint replacement surgery will change the way surgeons bill for and price knee and hip replacements, but COVID-19 is delaying the process.

In February, the CMS plan was to invite comments on the rule changes until April 24, and to institute changes in December, when the current rules for joint replacement surgery were set to expire.

But the COVID-19 pandemic has changed many things, including the timing of the new comprehensive care for joint replacement model. Last week, CMS announced that the original rules would be extended by 3 months, until March 31, 2021, and that the comment deadline would be extended to June 23.

The extensions were welcome news for orthopedic surgeons, but, "given the deep financial impact of COVID-19 on participants and the health outcomes of their patients," the academy is advocating for the original rule to be extended to the end of 2021, said Wilford Gibson, MD, chair of the AAOS Council on Advocacy.

We remain strongly opposed to the mandatory nature of the model and are disappointed that the proposed extension excludes voluntary participants.

"In the comprehensive care for joint replacement model 3-year extension proposed rule, CMS put forth some important changes to reflect the versatility of site of care and to further burden reduction," Gibson told Medscape Medical News. "However, we remain strongly opposed to the mandatory nature of the model and are disappointed that the proposed extension excludes voluntary participants. In continuing our work with CMS to improve musculoskeletal care, we hope that the agency will address these key concerns."

The original comprehensive care for joint replacement model came into effect in April 2016, with the goal of providing better, more efficient care for Medicare and Medicaid patients undergoing hip and knee replacements. Those are the most common inpatient surgeries for Medicare beneficiaries, according to CMS.

Initially, the model was designed to test bundled payment and quality measurement for an episode of care for one of those surgeries, from diagnosis through follow-up. By most accounts, the model, now entering its fifth year, has worked well.

It is not the kind of thing most patients would notice, said Michael Barnett, assistant professor of health policy and management at the Harvard T.H. Chan School of Public Health in Boston. However, in a 2019 review of the first 2 years of the model, Barnett and his colleagues found a modest decrease in the cost of joint replacements, with no change in complication rates.

Bundled Payments, Quality Measures

"It's an administrative billing designation that gives hospitals a less-intense way to manage their knee replacement patients that's exactly analogous to inpatient status," Barnett told Medscape Medical News.

The revisions proposed by CMS expand the definition of episode of care to include outpatient procedures for total knee arthroplasty and total hip arthroplasty; adjust the target price calculation, so that clinics will base price on 1 year of claims data, rather than the 3 used under the original rule; and change the reconciliation periods, moving from two, conducted 2 and 14 months after the end of a performance year, to one, conducted 6 months after the end of a performance year.

"Changing it to 1 year makes it harder, potentially, to make money on the bundled payments," Barnett said. "But this is all by design; CMS can design the program however they want. The question is how hard it is going to be to get shared savings out of this model."

That remains to be seen. "The devil is in the details," he said, and your perspective "depends where you're sitting."

The program is mandatory, as is the 3-year extension period, although not for voluntary participants.

The AAOS appears to be supportive of the CMS plan to include outpatient total knee arthroplasty and total hip arthroplasty in the revised model, but notes that there is a chance that the new designation could result in higher-risk patients being moved to outpatient settings.

The plan to base pricing on the most recent year of claims data could also present problems.

With COVID-19 still threatening lives around the United States and elective surgeries cancelled or postponed in most places, the 2020 data will almost certainly be skewed.

"A lot of orthopedic surgeons are doing very poorly right now," Barnett explained, pointing out that "a lot of these surgeries are not happening because of COVID-19."

"In general, though, I think the rule changes that CMS is proposing all sound like very reasonable tweaks to a policy," he added. "They are just adapting to the healthcare landscape as it has changed over the last few years."

American Academy of Orthopaedic Surgeons (AAOS) 2020 Annual Meeting.

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