In the final days of 2016, CMS finalized new mandatory bundled payment models for cardiac and orthopedic care, set to launch this year. The final rule also made several modest adjustments to the existing Comprehensive Care for Joint Replacement (CJR) model (finalized in late 2015 and currently underway). The final rule is published in the January 3, 2017 Federal Register.
These models emphasize a push to shift Medicare from a volume- to value-based payment system that encourages care coordination and quality. (“CMS Finalizes New Bundled Payment, ACO Models,” AHLA Weekly, December 23, 2016)
The new payment models, and the updated CJR model, give clinicians the opportunity to qualify for a 5 percent incentive payment through the Advanced Alternative Payment Model (APM) path under the under the Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act (MACRA), CMS said. (Advancing Care Coordination through Episode Payment Models (Cardiac and Orthopedic Bundled Payment Models) Final Rule (CMS-5519-F) and Medicare ACO Track 1+ Model, Fact Sheet, CMS.gov, December 20, 2016)
These models will reward hospitals that work together with physicians and other providers to avoid complications, prevent hospital readmissions, and speed recovery.
The announcement finalizes significant new policies that:
Improve cardiac care: Three new payment models will support clinicians in providing care to patients who receive treatment for heart attacks, heart surgery to bypass blocked coronary arteries, or cardiac rehabilitation following a heart attack or heart surgery.
Improve orthopedic care: One new payment model will support clinicians in providing care to patients who receive surgery after a hip fracture, other than hip replacement. In addition, CMS is finalizing updates to the CJR Model, which began in April 2016.
Provides an Accountable Care Organization opportunity for small practices: The new Medicare ACO Track 1+ Model will have more limited downside risk than Tracks 2 or 3 of the Medicare Shared Savings Program in order to encourage more practices, especially small practices, to advance to performance-based risk.
The intent of the bundled payment models is to further provider collaboration and sharing of best practices. In the CJR model, approximately 90 percent of hospitals participating in the model are fostering education, outreach, communication, and collaboration. These new models advance CMS’ goal of improving the efficiency and quality of care for Medicare beneficiaries and encourage hospitals, physicians and post-acute care providers to work together to improve the coordination of care from the initial hospitalization through recovery. (Advancing Care Coordination through Episode Payment Models (Cardiac and Orthopedic Bundled Payment Models) Final Rule (CMS-5519-F) and Medicare ACO Track 1+ Model, Fact Sheet, CMS.gov, December 20, 2016)
These models are being implemented by the CMS Innovation Center with participation by all hospitals in selected geographic areas in order to yield more generalizable results, and additional protections for small and rural providers. The models will be referred to as:
- The Acute Myocardial Infarction (AMI) Model
- The Coronary Artery Bypass Graft (CABG) Model
- The Surgical Hip and Femur Fracture Treatment (SHFFT) Model
- The Cardiac Rehabilitation (CR) Incentive Payment Model
Acute care hospitals in certain selected geographic areas will participate in retrospective episode-based payments for items and services that are related to AMI, CABG and SHFFT treatment and recovery, beginning with a hospitalization and extending for 90 days following hospital discharge.
The first performance period for the new episode payment models (the AMI, CABG, and SHFFT Models) and the Cardiac Rehabilitation Incentive Payment Model will begin on July 1, 2017. The duration of the models is until December 31, 2021.
The final rule also makes adjustments to the CJR (Model, allowing the model to qualify as an Advanced APM under the Quality Payment Program as well as aligning the model’s policies with the episode payment models around financial arrangements and beneficiary engagement incentives, compliance enforcement, appeals processes and beneficiary notifications.
ACO Track 1+ Model
CMS said the new Track 1+ Model is based on Track 1 of the Medicare Shared Savings Program (MSSP), with a maximum 50 percent shared savings rate, “but incorporates elements of Track 3.”
The new model will be open to MSSP Track 1 ACOs that are within their current agreement period, initial applicants to the MSSP and Track 1 ACOs renewing their agreement.
CMS said additional details on Track 1+ are forthcoming. (Advancing Care Coordination through Episode Payment Models (Cardiac and Orthopedic Bundled Payment Models) Final Rule (CMS-5519-F) and Medicare ACO Track 1+ Model, Fact Sheet, CMS.gov, December 20, 2016)
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