CJR PROs: Easier than you think so don’t miss the opportunity

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The current state of play

Bundled payments were a big topic at HIMMS17 and there were several sessions focused on the Comprehensive Care for Joint Replacement (CJR) mandatory bundled payment program from CMS targeted at hip and knee replacement surgeries. In a session entitled “Lessons Learned from the Mandatory Joint Replacement Bundle” the VP of Health Informatics at Aurora Health Care talked about how they had successfully implemented the program and some of their lessons learned. Surprisingly the word on the street was that few CJR organizations are collecting patient-reported outcomes (PROs) in this bundle, let alone reporting their results and claiming the voluntary 10% top up to their composite score, in my opinion an opportunity missed.

CJR PROs explained

The CJR program is tough to get your head around initially but thanks to an increasing amount of publicly available documentation from CMS many of the details are becoming easier to digest. Surprisingly, the patient-reported outcomes requirements are fairly easy to satisfy if you boil it down to the basics:

A simple choice of patient-reported measures

CMS have opted for a relatively straightforward approach here, giving the option of two general quality of life measures: the VR-12 (12 questions) and the PROMIS Global-10 (10 questions) and the option of two condition specific measures, the Hip disability and Osteoarthritis Outcome Score (HOOS, a 27 question subset of the broader 40 question survey) and Knee injury and Osteoarthritis Outcome Score (KOOS, a 28 question subset of the broader 40 question survey). After the comment period they also added the option of instead using the HOOS, JR and KOOS, JR which are shortened 6 question versions of the long-form HOOS and KOOS.

Pre and post snapshots with some case mix variables

CMS have decided to keep things simple, asking for one pre-operative assessment at any time 3 months prior to surgery and one post-operative assessment between 270 to 365 days after surgery. Along with the pre-operative assessment, CMS want a few additional pieces of information, 3 pieces of which are patient-reported: patient-reported pain in the non-operative lower extremity joint, the Single Item Health Literacy Screening Questionnaire (SILS2) that simply asks: “How comfortable are you filling out medical forms by yourself?” and a single question taken from the Oswestry Disability Index: “My back pain at the moment is: none, very mild, moderate, fairly severe, very severe, worst imaginable”. Below is the table shown in CMS’ CJR FAQ that very nicely summarizes the requirements including elements that could be pulled from the EHR or patient notes:


Who’s Included

A critical component of being successful under CJR is undoubtedly being able to identify which patients will be counted under the program. CMS include a useful flowchart of simple questions in their FAQ, some inclusion criteria are: 1) TKA/THA patients, 2) Only primary total joint replacement, 3) The absence of a pelvic, hip or femur fractures, 4) The absence of malignant relevant neoplasms 5) No removal of implanted devices or prostheses and not undergoing procedure for mechanical complication of prior THA/TKA, 6) Patient must be enrolled in Medicare FFS and Aged 65 or above.

Start with small patient numbers

Possibly the best news about CJR PRO reporting is the number of patients you’re required to collect PRO data for in order to qualify – in the first year its either >50% of qualifying cases or more than 50 qualifying cases. This ramps up over time but even then the numbers sound realistic and are clearly aimed at encouraging organizations to just get started. As an illustration, a hospital that performs 20 qualifying cases would only be required to report data for 10. In contrast a hospital carrying out 1000 qualifying cases would only be required to report data for 50. This sets a very low bar for getting your points in!

Easy Excel file reporting

CMS have provided simple a data dictionary and Excel template for reporting data. Reporting is performed securely through QualityNet by uploading your completed Excel template. Another aspect to consider are the reporting timeframes for the Performance Years. We’re already in Performance Year 2, so if you didn’t already collect pre-operative PROs in Year 1 (that ended August 31, 2016) you’re already playing catch up and won’t have matched post-operative data to report in our current Performance Year 2. These two graphics from CMS’ CJR FAQ provide a good overview of the important dates:

CJR Data Collection Time Frames

CJR Data Reporting Time Frames

Wrapping up

It’s easy to understand why there was so much kick-back when the CJR program was introduced, it’s a complicated program that has been forced on a large number of hospitals at a time of unprecedented change. That said, after peeling back some of the details, it appears to be well intentioned, carefully thought through and not as complicated as it first looks.

The patient-reported outcomes component represents a significant opportunity to give yourself an advantage in this program and build organizational capability that can be applied to similar programs that are likely to come from both CMS and private payers. Starting now will only amplify in impact as the teeth of the CJR program bite in subsequent performance years. Failing to collect pre-operative PRO data for your CJR patients this year means you won’t be able to provide matched post-operative data next year, so mind the gap!

I hope this has been useful to some of the organizations out there trying to figure out their strategy. At Outcomes.com we help organizations deal with some of this complexity and start collecting PROs data with minimal workflow interruption. If you’d like to explore how we might be able to help, we’d love to hear from you!

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