Master Episode-based payment Initiatives

This 3 Hospital System Reduced CJR Patient Complications by 19% and Readmission by 38%

Drive the Clinical Actions that Will Reduce Risk and Cost Across Each Care Episode

As part of a drive toward innovation, the Centers for Medicare & Medicaid Services (CMS) continues to roll out episode-based payment initiatives focused on improving cardiac and orthopedic care. These programs include the current Comprehensive Care for Joint Replacement (CJR) model and proposed:

  • Acute Myocardial Infarction (AMI) Model;
  • Coronary Artery Bypass Graft (CABG) Model;
  • Surgical Hip and Femur Fracture Treatment (SHFFT) Model; and
  • Cardiac Rehabilitation (CR) Incentive Payment Model

These models all share common goals aimed at enabling collaboration, communication, and prevention; and improving the quality and efficiency of care for Medicare patients. The distinct feature of episode-based payments is the incentive to deliver better care at a lower cost from the time a patient is admitted through 90 days post-discharge.

The carrots and sticks that are core to the program have helped to deliver significant savings across participating providers. In a recent study published in JAMA Internal Medicine, covered episodes under the current CJR saw a decrease of $5577 or 20.8%. New bundles, which are scheduled to go live in July 2017, will extend the current program to include patients admitted for heart attacks, bypass surgery, and/or cardiac rehabilitation following a heart attack or heart surgery. The CJR program will be replaced by the SHFFT model, which extends the covered treatments to include patients who receive surgery after a hip fracture.

Mastering your CJR patient population means that your patients are healthier, you better allocate your resources, and that you avoid potential repayments to Medicare at the end of the model performance year.

Jvion's Cognitive Clinical Success Machine is specifically designed to help providers manage at-risk, episode-based bundled payment models by empowering providers with a high-definition view into patient predispositions, risk manifestations, that the actions and interventions that will:

  • Identify - at the time of admission - patients who are likely to have a nosocomial event
  • Optimize the inpatient length of stay
  • Stop 30/60/90 day readmissions
  • Align patients that the post-acute care environment that will drive the best quality outcomes
  • Reduce risk across care transition points
  • Enable the best care action paths to improve outcomes while reducing costs

Jvion's Cognitive Clinical Success Machine accounts for the massive and complex body of patient data including the exogenous factors that account for 60% of a person's health outcomes. The machine does this using a quadrillion cognitive machine dimensions and up to 10,000 factors to enable a high definition view of the patient 30, 60, 90 and up to 365 days into the future. This view accounts for the full patient portrait of risk across all care settings and enable the best action paths that will prevent avoidable complications and improve outcomes. When applied to a specific bundle, providers are enabled with the tool and recommendations they need to drive individualized interventions at every point across the episode of care.

CJR Program – Topic Deep Dive

The CJR program is an outcomes-based payment model that holds participating hospitals accountable for hip or knee replacement surgery (MS-DRG 469/470) patients. More than 400,000 people have hip or knee replacements every year making these events the most common inpatient surgeries for Medicare beneficiaries. The price tag for these episodes add up to more than $7B annually with costs and quality varying widely across providers.

In an effort to curb spend and improve outcomes, CMS proposed the CJR model in July 2015 with the final rule and model going live in April 2016. Sixty-seven geographic areas including 791 hospitals are impacted. Participating hospitals are accountable for the hip or knee episode of care from the time a person is admitted to 90 days following discharge.

The price tags for hip and knee replacements add up to more than $7B annually with costs and quality varying widely across providers.

The model works by setting a target price for the covered episode for each participating hospital. Throughout the year, hospitals are reimbursement through the existing fee-for-service model. At the end of the year, payments are reconciled to the established CJR target. If the total payments made are less than the established price, a hospital will receive a payment; if the total payments made are more than the established price, a hospital will have to repay some or all of the difference.

Included within the CJR program are quality measures. These include a compliance measure, a patient satisfaction measure, and a self-reported patient-reported outcome measure. A hospital’s quality score will impact CJR payment in two ways:

  • If a hospital receives a poor quality score, they will be ineligible to receive reconciliation payments regardless of performance on cost
  • The composite quality score will determine the "effective discount percent" for reconciliationand repayments

Taken together - from bundling to predicating payments on quality measures-the aim of the CJR program is to drive accountability across hospitals, physicians, and other providers so that they will be incentivized to work together and deliver better care.


For more information on the CJR program, please visit the CMS CJR information page at ​

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