The Consumer Impact

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Woman with a cane walking down the stairsTranslating utilization data into outcomes for patients is a significant component of CJR. There are two quality measures included in the model – total hip arthroplasty and/or total knee arthroplasty (THA/TKA) complications measure (NQF #1550) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure (NQF #0166). In addition, CJR incentivizes the submission of patient-reported outcomes (PRO) and limited risk variable data following eligible elective primary THA/TKA procedures. Submission of these data is not mandatory for reconciliation payment eligibility. However, hospitals that do submit these data may increase their financial opportunity under the model.

CJR hospitals can use one of two surveys in each of two categories of surveys to satisfy the voluntary PRO data submission.

These surveys, which are self-administered, focus on how the person feels and how well he or she is able to do usual activities, emotional well-being, pain, social activities and roles and functional status. The surveys must be collected during both the pre- and post-operative data collection timeframes. Performance on the data elements is not considered when CMS assigns composite quality score points, as described below.

The CJR model uses a composite quality score methodology to link quality to payment. Hospitals earn points from their performance on the two quality measures noted above, as well as from demonstrating improvement on either or both of the quality measures. If they submit the PRO and limited risk variable data, hospitals can earn an additional two points. The sum of the components makes us the composite quality score which is capped at 20 points.

A hospital’s score is incorporated into the pay-for-performance methodology, which assigns the hospital to one of four quality categories (Excellent, Good, Acceptable, Below Acceptable) at the time of reconciliation for a performance year. Hospitals must have a composite score equal to or greater than 5.0 to be eligible for a reconciliation payment.

For performance year 1, 21 New Jersey hospitals in CJR qualified through their performance on the quality measures for a reconciliation payment. Five earned their payments by achieving a score in the “Excellent” category, and 14 earned their payments with a score in the “Good” category. The remaining two had scores in the “Acceptable” category.

The preliminary data for performance year 2 shows that 25 N.J. hospitals could qualify for a reconciliation payment. Six have a preliminary quality score in the Excellent category; 16 have a preliminary score in the “Good” category. Three have a preliminary score in the “Acceptable” category.