episode payment models

September 7, 2017

Posted on by hortyspringer

QUESTION:        I heard that CMS is planning to cancel its upcoming episode payment models.  Is this true?

ANSWER:            Yes.  In mid-August, CMS issued a proposed rule that would cancel its upcoming episode payment models (“EPMs”) and cardiac rehabilitation incentive payment model.  The rule also proposed revisions to the existing Comprehensive Care for Joint Replacement model (“CJR program”).  This proposal marks a significant change of course for the agency’s regulatory agenda, given that CMS had previously expressed an intent only to delay these models, not cancel them outright.

The upcoming EPMs would have affected Medicare beneficiaries undergoing services related to acute myocardial infarctions, coronary artery bypass grafts, and surgical hip/femur fracture treatment.  The rule has not been finalized, so the ultimate fate of these payment models remains uncertain.  CMS will continue to accept comments (as part of the standard notice and comment rulemaking process) on this proposal until October 16, 2017.

If the proposed rule is finalized, it will also give hospitals participating in the CJR program a one-time opportunity to exit the program.  This is likely the beginning of a future trend away from mandatory payment models (such as the CJR program) in favor of voluntary value-based payment programs.

We continue to recommend that you build flexibility into your planning processes to account for this uncertainty in CMS’s rulemaking activities.

The proposed rule is available here.

July 13, 2017

Posted on by hortyspringer

QUESTION:        I heard that CMS is planning to introduce new episode payment models.  When will these take effect?

ANSWER:            As many of you know, CMS has spent the past several years trying to move away from traditional fee-for-service medicine.  Some of you are likely already participating in the Comprehensive Care for Joint Replacement model, which provides value-based payment for certain types of lower extremity joint replacement procedures.  CMS has recently finalized new policies to implement three new episode payment models (“EPMs”).  The EPMs will apply to Medicare beneficiaries undergoing services related to acute myocardial infarctions (the “AMI model”), coronary artery bypass grafts (the “CABG model”), and surgical hip/femur fracture treatment (the “SHFFT model”).

In the spring of this year, CMS publicized its intent to delay the effective date of these three EPMs.  CMS explained that it agreed with commentators who had asked for more time to prepare for this new payment structure.  CMS also reasoned that the delay would give the agency more time to make modifications, if necessary.  Consequently, the effective date of the AMI model, CABG model, and SHFFT model has been delayed until January 1, 2018.

In addition to these three EPMs, there will also be a cardiac rehabilitation incentive payment model.  This is designed to reduce hospitalizations and preserve medical resources by encouraging affected beneficiaries to take advantage of cardiac rehabilitation.  CMS reasoned that it would be confusing and operationally challenging to implement this cardiac rehabilitation model in 2017.  For ease of implementation, it delayed the cardiac rehabilitation model to January 1, 2018 as well.

Although CMS has expressed a firm intent to proceed with the planned EPMs and cardiac rehabilitation model, it is possible that the agency will make significant further changes before 2018.  We recommend that you build some flexibility into your planning process to account for this uncertainty.