Care for Joint Replacement Measures


Quality metrics affect payments in CJR, do you know the tools?

By Craig Johnson, PT, MBA

The new Comprehensive Care for Joint Replacement (CJR) program was rolled out on April 1, 2016, by the Centers for Medicare & Medicaid Services (CMS) (see previous Impact articles on the CJR). In this bundled payment model, quality measures play a big role in determining whether a convener receives a reconciliation payment or makes a repayment to CMS. While you might not be involved in a CJR program, this article provides you an opportunity to learn about the quality measures in CJR, but for physical therapy (PT) providers wishing to collaborate with hospitals it is critical to understand the quality measures. Private practice PTs are allowed to negotiate “collaborator” agreements and share in up/downside risk with the hospital “convener.” Practice owners must not only understand their costs, but also understand the quality measures that will impact payment adjustment. This article will take a closer look at the quality measures used in the CJR. You will learn about the mandatory and voluntary quality measure tools, the timing of measure capture, and how it affects payment adjustment.

Required Quality Measures

There are two required quality measures in the CJR bundle. The first is the hospital-level risk-standardized complication rate (RSCR) following elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA) (NQF #1550). The measure outcome is the rate of complications occurring after THA and/or TKA surgical procedures during a 90-day period following the date of the index admission for a specific hospital. One or more of the following complications are considered in the measure:

  • acute myocardial infarction
  • pneumonia, or sepsis/septicemia within 7 days of admission
  • surgical site bleeding, pulmonary embolism, or death within 30 days of admission
  • mechanical complications, periprosthetic joint infection, or wound infection within 90 days of admission

While this measure is currently collected by hospitals, physical therapists can play a significant role in monitoring complications during post-op rehabilitation that might lead to readmission or additional costs.

The second mandated quality measure is the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey measure (NQF #0166). The HCAHPS Survey measures patient perceptions of their hospital experience. The HCAHPS Survey asks recently discharged adult patients 32 questions about aspects of their hospital experience. The core of the survey contains 21 items that ask “how often” or whether patients experienced a critical aspect of hospital care. Eleven HCAHPS measures (seven composite measures, two individual items, and two global items) are publicly reported on the Hospital Compare website:

The seven composite measures summarize the following:

  • how well doctors communicate with patients.
  • how well nurses communicate with patients.
  • how responsive hospital staff are to patients’ needs.
  • how well hospital staff help patients manage pain.
  • how well the staff communicates with patients about medicines.
  • whether key information is provided at discharge.
  • how well the patient was prepared for the transition to posthospital care.

Voluntary Quality Measures

Voluntary quality measures THA/TKA PRO-PM (patient-reported outcomes and performance measures) in years 1–3 are anticipated to be integrated as a mandatory measure in years 4 and 5, with details to be proposed during future rulemaking. CMS is interested in PROs and performance measures because it allows them to assess postoperative outcomes and analyze data in order to:

  • Determine a narrow set of risk factors for statistical risk adjustment of patient-reported outcomes.
  • Examine the differences in hospital performance related to different components in the patient-reported outcomes (such as functional status, pain, etc.) for statistical modeling for risk adjustment.
  • Evaluate the reliability of the patient-reported outcome measure.
  • Examine and test validity of the patient-reported outcome measure in the risk adjustment model using testing methods such as face validity testing with national experts compared to similar results based on other data sources.

The challenge, as you see in the table, is the timing of measure capture, particularly at 270 and 365 days post-op. Ultimately the responsibility lies with the hospital convener to report quality scores; however, physical therapists in private practice can demonstrate value by understanding the measures and where they can contribute.

PROMIS, the Patient-Reported Outcomes Measurement Information System, measures physical, mental, and social health and can be used across chronic conditionsii. Domain definitions include physical function, fatigue, pain, emotional distress (including depression, anxiety, and anger), social health (including social function and social support), and global health. PROMIS is a measure whose scores can be compared across diseases and conditions, thus capturing patient global health. The VR (Veterans RAND)-12 is a 12-question survey that assesses similar domains and summarizes the score using Physical Health Summary Measure and Mental Health Summary Measure scores. The CJR regulations for voluntary reporting require collection of either the PROMIS-Global or VR-12.

HOOS and KOOS, Hip Injury and Osteoarthritis Outcome Score and Knee Injury and Osteoarthritis Outcome Score, collects data on five hip- or knee-specific patient-reported outcomes. Five domains captured in either HOOS or KOOS include: (1) pain; (2) symptoms: other symptoms such as swelling, restricted range of motion and mechanical symptoms; (3) ADL: disability on the level of daily activities; (4) sport/rec: disability on a level physically more demanding than activities of daily living; (5) QOL: quality of life, mental and social aspects such as awareness and lifestyle changes.iii Items for HOOS and KOOS were selected based on: (1) the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), version 3.0; (2) a literature review; (3) an expert panel (patients referred to physical therapy for knee injuries, orthopedic surgeons, and physical therapists from Sweden and the U.S.); and (4) a pilot study of two questionnaires (one for symptoms of ACL injury, one for symptoms of OA) in individuals with posttraumatic OA.iv

Additional PM (performance management) measures include body mass index (BMI); pain; quantified spinal pain; objective measures of motion, strength, and gait; congenital joint conditions; and health literacy. These PRO-PM measures should be familiar measures to physical therapists. If not, you should become familiar with these measures that will effect payment.

Quality Composite Score

A composite quality score is computed for each participant hospital, which summarizes the hospital’s level of quality performance and improvement on specified quality measures. The composite quality score assigns different weights to each of the measures:

  • 50 percent for the hospital-level RSCR following elective primary THA and/or TKA (NQF #1550)
  • 40 percent for the HCAHPS Survey measure (NQF #0166)
  • percent for the THA/TKA voluntary patient-reported outcomes data submission. Based on quality scores, each hospital is placed in one of four levels.

The discount for all participant hospitals is 3.0 percent, which will be adjusted by the quality composite score; thus hospitals will have either less repayment responsibility (that is, the quality incentive payment will offset a portion of their repayment responsibility) or receive a higher payment (that is, the quality incentive payment would add to the reconciliation payment) at reconciliation. Measure for measure, quality metrics will be used in bundled models of value-based payment. Now is an excellent time to learn about the measures and understand how your hospital partner is impacted by the scores before you negotiate.

iCMMI Comprehensive Care for Joint Replacement Model: Quality Measures, Voluntary Data, Public Reporting Processes for Preview Reports. Accessed April 20, 2016.

iiPROMIS Dynamic Tools to Measure Health Outcomes from the Patient Perspective Accessed May 9, 2016.

iiiPhysical Performance Measures, OARSI set of recommended physical performace measures for hip and knee osteoarthritis. Accessed May 9, 2016.

ivRoos, E. M. and L. S. Lohmander (2003). “Knee injury and Osteoarthritis Outcome Score (KOOS): from joint injury to osteoarthritis.” Health Qual Life Outcomes 1: 64.


1. Centers for Medicare & Medicaid Services. Comprehensive Care for Joint Replacement Model. Accessed May 4, 2016.

2. Federal Register. Medicare Program; Comprehensive Care for Joint Replacement Payment Model Acute Care Hospitals Furnishing Lower Extremity Joint Replacement Services. November 24, 2015. Accessed April 20, 2016.

3. American Physical Therapy Association. Comprehensive Care for Joint Replacement Model (CJR). Accessed May 7, 2016.

Craig Johnson, PT, MBA, is a PPS member and partner of Therapy Partners, Inc. in Minnesota. He can be reached at

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