CMS Releases Advancing Care Coordination Through Episode Payment Models Final Rule

As part of its efforts to encourage coordinated care, improve quality of care and decrease costs, the Centers for Medicare and Medicaid Services (CMS) posted an update to the final rule for implementing mandatory bundled payment models for cardiac services, as well as two other significant policies.

The program start date for the Advancing Care Coordination through Episode Payment Models (EPMs) final rule will now be Jan. 1, 2018.

  • Creates mandatory episode payment models (EPMs) for acute myocardial infarction (AMI) (triggered by admissions for AMI and admissions representing percutaneous coronary intervention treatment for AMI) and coronary artery bypass (CABG) for acute care hospitals.
    • The final rule also includes an EPM for surgical hip or femur fracture treatment.
  • Gives eligible clinicians, including physicians and non-physician practitioners, the opportunity to qualify as participating in Advanced Alternative Payment Models (APMs) through EPMs.
  • Introduces a cardiac rehabilitation incentive payment to increase utilization of cardiac rehabilitation services for heart attack and bypass surgery Medicare beneficiaries.

CMS has selected 1,120 hospitals to participate in the AMI and CABG models. Hospitals will not be able to apply to participate. Under the final rule, participation in EPMs and the cardiac rehab incentive payment will begin Jan 1, 2018 and run through Dec. 31, 2021. Performance assessment will occur at the end of each calendar year.

I. EPISODE PAYMENT MODELS

Episode Initiation: For both AMI and CABG EPMs, the episode will begin upon inpatient admission to an anchor hospital. If a patient is not admitted, no episode is initiated. Care will include both medical and surgical services provided to the beneficiary during the inpatient stay through 90 days after discharge.

  • AMI Episode – triggered by admissions for AMI (MS-DRGs 280-282) or admissions representing PCI treatment for AMI (MS-DRGs 246-251) where the AMI ICD code can be a primary or secondary diagnosis
  • CABG Episode – triggered by claims for CABG (MS-DRGs 231-236)

AMI and CABG Episode Inpatient to Inpatient Transfers:

  • If a beneficiary is admitted to a participating initial treating hospital that is an AMI or CABG model participant for an AMI MS-DRG or PCI MS-DRG with AMI ICD-CM diagnosis code, and this participating hospital transfers the patient to another participating hospital, the episode will be initiated at the participating receiving hospital.
  • If a beneficiary is admitted to a nonparticipating initial treating hospital that is an AMI or CABG model participant for an AMI MS-DRG or PCI MS-DRG with AMI ICD-CM diagnosis code, and this nonparticipating hospital transfers the patient to a participating hospital, the episode will begin at the participating receiving hospital.
  • If a beneficiary is admitted to an initial treating hospital participating in an AMI or CABG model for an AMI MS-DRG or PCI MS-DRG with AMI ICD-CM diagnosis code to a nonparticipating hospital, no episode is initiated.

Specific Services Included: Medicare Parts A and B

Beneficiary Inclusion Criteria: Beneficiaries must have Medicare as their primary payer and be enrolled in Medicare Part A and Part B. Eligibility for Medicare cannot be based on end-stage renal disease (ERSD).

Overlap with Other CMS Programs:

Beneficiary Overlap: Beneficiaries already participating in any Bundled Payments for Care Improvement (BPCI) episode are excluded from EPMs. EPM episodes will be cancelled if the beneficiary in an EPM initiates any BPCI episode. Beneficiaries are excluded from participating in EPMs if they are enrolled in a managed care plan (such as Medicare Advantage, health care prepayment plans or cost-based HMOs), covered under a United Mine Workers of America health care plan or attributed to a Next Generation ACO, Comprehensive ESRD Care Model incorporating downside risk for financial losses or a Medicare Shared Savings Program Track 3 ACO. However, hospitals participating in organizations located in selected metropolitan statistical areas (MSAs) may admit and treat patients who are not attributed to the above types of ACOs, and in this case, can serve as EPM collaborators. If these patients are discharged with DRGs covered under the EPM, then the hospital will be required to participate in the EPM for those discharges.

Provider Overlap: Beneficiaries cannot be under the care of an attending or operating physician, as designated on the inpatient hospital claim, who is a member of a physician group practice that initiates a BPCI Model 2 episode at the EPM participant hospital for an anchor MS-DRG under the EPM (MS-DRGs 231-236, 246-251 or 280-282). Acute care hospitals participating in BPCI Model 2 or 4 located in an MSA selected for EPM participation will participate in an EPM only for episodes anchored by EPM MS-DRGs that would not otherwise be a BPCI episode. Thus, BPCI episodes would take precedence over EPM episodes. In other words, if your hospital participates in BPCI but falls in one of the selected MSAs for EPM participation, your hospital may still be an EPM participant for episodes that are not covered under their BPCI agreement if it is located in an MSA selected for EPM participation. For example, a hospital participating in BPCI for CABGs only would still participate in EPMs for AMIs if they are located in one of the selected MSAs.

Financial Accountability: Acute care hospitals will be held financially accountable by CMS for all spending within the episode. Hospitals to which EPM beneficiaries are attributed are known as "EPM participants."

Eligibility to Enter Financial Sharing Arrangements as EPM Collaborators: An EPM participant can enter into financial sharing arrangements with EPM collaborators. An EPM collaborator is an ACO or one of the following Medicare-enrolled individuals or entities that enter into a financial sharing arrangement. Individuals include physicians, non-physician practitioners (physician assistants, nurse practitioners, clinical nurse specialists, certified registered nurse anesthetists, clinical social workers, registered dietician or nutrition professionals) and therapists (physical therapists, occupational therapists, speech-language pathologists) in private practice. Entities include providers of outpatient therapy services, hospitals, skilled nursing facilities (SNFs), home health agencies (HHAs), inpatient rehabilitation facilities (IRF), long-term care hospitals (LTCHs), comprehensive outpatient rehabilitation facilities (CORFs), physician group practices (PGPs), critical access hospitals (CAH), group practices with a valid, active tax identification number (TIN) that include at least one owner or employee who is a non-physician practitioner, but does not include a physician, owner or employee (NPPGP), therapy groups in private practices with a valid, active TIN that include at least one owner or employee who is a non-physician practitioner but does not include a physician owner or employee (TGP).

Geographical Areas Included: CMS randomly selected 98 MSAs for mandatory implementation of EPMs. See the full list of hospitals here.

Beneficiary Notification: Participant hospitals and collaborators are required to provide written notice.

Quality and Reporting: To receive payment, participants must meet quality targets. Participants will receive a composite quality score based on the metrics below.

AMI Episode:

  • Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following AMI Hospitalization (NQF #0230) based on at least 25 cases
  • Excess Days in Acute Care after Hospitalization for AMI based on at least 25 cases
  • Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey (NQF #0166) based on at least 100 surveys during four consecutive quarters of data
  • Voluntary: Hybrid Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following AMI Hospitalization (NQF #2473)

CABG Episode:

  • Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate Following CABG Surgery (NQF #2558)
  • HCAHPS Survey (NQF #0166)
  • Society of Thoracic Surgeons (STS) CABG composite score (NQF #0696)

Payment: EPMs are retrospective payment models. CMS will set target prices using a combination of historical hospital-specific data and regional data, adjusting for complexity of treatment. Payment occurs through a phased-in approach.

Evaluation: CMS will evaluate EPMS based on quality during the episode, after the episode ends and for longer durations. CMS will examine outcomes and patient experience measures. CMS has established an APMs Beneficiary Ombudsman to monitor the models and field inquiries from beneficiaries if needed.

For additional information on EPMs, please visit the CMS Innovation Center website

II. ADVANCED APM TRACK UNDER EPMs

CMS proposes that through participating in EPMs for AMI and/or CABG, eligible clinicians can choose to qualify as participating in an Advanced APM, if they:

  • Meet CEHRT use requirements in the Quality Payment Program as outlined in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), maintaining documentation on use and attestation
  • Keep an up-to-date list of financial arrangements under the EPM and submit to CMS quarterly

III. CARDIAC REHABILITATION INCENTIVE PAYMENT

CMS has selected 1,320 hospitals to participate in the Cardiac Rehabilitation Incentive Payment Model.

Payment: This is a retrospective payment based on total cardiac rehab use of beneficiaries attributable to participant hospitals:

  • For each of the first 11 services, an initial payment $25 per service
  • Afterwards, payment increases to $175 per service

Standard Medicare payments for cardiac rehab services for beneficiaries in the model will continue to be made directly to those providers.

Eligibility: CMS has selected hospital participants in 90 geographic areas, half of which are areas chosen for EPM participation while the other half are from areas that are not chosen for EPM participation. For additional information, visit the CMS Innovation Center website

Keywords: Centers for Medicare and Medicaid Services (U.S.), Episode of Care, Medicaid, Medicare Access and CHIP Reauthorization Act of 2015, Medicare Part A, Medicare Part C


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