Proposed Rule2023-15169
Request for Information; Episode-Based Payment Model
Primary source
Metadata and text below are from the Federal Register, a public-domain U.S. government work. Always verify the official published version before relying on it for any legal matter.
Published
July 18, 2023
Issuing agencies
Health and Human Services DepartmentCenters for Medicare & Medicaid Services
Abstract
This request for information seeks input from the public regarding the design of a future episode-based payment model. Responses to this request for information may be used to inform potential future rulemaking or other policy development.
Full Text
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<title>Federal Register, Volume 88 Issue 136 (Tuesday, July 18, 2023)</title>
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[Federal Register Volume 88, Number 136 (Tuesday, July 18, 2023)]
[Proposed Rules]
[Pages 45872-45881]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2023-15169]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Chapter IV
[CMS-5540-NC]
RIN 0938-AV19
Request for Information; Episode-Based Payment Model
AGENCY: Centers for Medicare & Medicaid Services (CMS), Department of
Health of Human Services (HHS).
ACTION: Request for information.
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SUMMARY: This request for information seeks input from the public
regarding the design of a future episode-based payment model. Responses
to this request for information may be used to inform potential future
rulemaking or other policy development.
DATES: To be assured consideration, comments must be received at one of
the addresses provided below, by August 17, 2023.
ADDRESSES: In commenting, refer to file code CMS-5540-NC.
Comments, including mass comment submissions, must be submitted in
one of the following three ways (please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments on this
regulation to <a href="https://www.regulations.gov">https://www.regulations.gov</a>. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-5540-NC, P.O. Box 8013,
Baltimore, MD 21244-8013.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-5540-NC, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
[[Page 45873]]
FOR FURTHER INFORMATION CONTACT:
Sacha Wolf, (410) 786-9769 (<a href="/cdn-cgi/l/email-protection#2e7d4f4d464f00794142486e4d435d0046465d00494158"><span class="__cf_email__" data-cfemail="8bd8eae8e3eaa5dce4e7edcbe8e6f8a5e3e3f8a5ece4fd">[email protected]</span></a>), for issues
related to incentive structure, model overlap, and BPCI Advanced.
Lauren Vanderwerker (<a href="/cdn-cgi/l/email-protection#e6aa8793948388c8b087888283949183948d8394a6858b95c88e8e95c8818990"><span class="__cf_email__" data-cfemail="e8a4899d9a8d86c6be89868c8d9a9f8d9a838d9aa88b859bc680809bc68f879e">[email protected]</span></a>) for issues
related to payment and Comprehensive Care for Joint Replacement (CJR).
Nicholas Adcock (<a href="/cdn-cgi/l/email-protection#602e0903080f0c01134e2104030f030b20030d134e0808134e070f16"><span class="__cf_email__" data-cfemail="56183f353e393a37257817323539353d16353b25783e3e2578313920">[email protected]</span></a>) for issues related to
health equity.
Dena McDonough (<a href="/cdn-cgi/l/email-protection#4a0e2f242b6407290e2524253f2d220a29273964222239642d253c"><span class="__cf_email__" data-cfemail="682c0d060946250b2c0706071d0f00280b051b4600001b460f071e">[email protected]</span></a>) for issues related to
quality measures, clinical episodes, or any other issues.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following
website as soon as possible after they have been received: <a href="https://www.regultions.gov">https://www.regultions.gov</a>. Follow the search instructions on that website to
view public comments. CMS will not post on <a href="http://Regulations.gov">Regulations.gov</a> public
comments that make threats to individuals or institutions or suggest
that the commenter will take actions to harm an individual. CMS
continues to encourage individuals not to submit duplicative comments.
We will post acceptable comments from multiple unique commenters even
if the content is identical or nearly identical to other comments.
I. Background
In 2021, the Innovation Center announced a strategic refresh with a
vision of having a health care system that achieves equitable outcomes
through high quality, affordable, person-centered care.\1\ To guide
this updated vision, the Innovation Center intends to design,
implement, and evaluate future episode-based payment models with a
focus on five strategic objectives, including advancing health equity
and driving accountable care.\2\ With a bold goal of having 100 percent
of Medicare fee-for-service (FFS) beneficiaries and the vast majority
of Medicaid beneficiaries in an accountable care relationship by 2030,
we acknowledge that additional opportunities for accountable care
relationships with specialists are needed.\3\
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\1\ CMS White Paper on CMS Innovation Center's Strategy: Driving
Health System Transformation--A Strategy for the CMS Innovation
Center's Second Decade (<a href="https://innovation.cms.gov/strategic-direction">https://innovation.cms.gov/strategic-direction</a>-whitepaper).
\2\ The five strategic objectives are Drive Accountable Care,
Advance Health Equity, Support Innovation, Address Affordability,
and Partner to Achieve System Transformation.
\3\ Providers in accountable care relationships work together
and with their patients to manage patients' overall health, all
while considering their patients' personal health goals and values.
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One approach to support accountable care and to create an avenue
for specialists to participate in value-based care initiatives is
through episode-based payment models. The Innovation Center has
launched several episode-based payment models (also known as bundled-
payment models), four of which are either ongoing or being implemented
in 2023.\4\ These models help to address the inefficiencies in
traditional Medicare FFS, where providers are paid for each item or
service, which may drive volume over value and fragment care. By
bundling items and services into an episode of care, providers are
better incentivized to coordinate patient care and to avoid duplicative
or unnecessary services.
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\4\ CMS Innovation Center models still ongoing or being
implemented in 2023 are the Bundled Payments for Care Improvement
Advanced Model, Comprehensive Care for Joint Replacement Model,
Enhancing Oncology Model, and the End-Stage Renal Disease Treatment
Choices Model.
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Early episode-based payment demonstrations were narrow in scope and
assessed particular design aspects, such as the use of gainsharing
mechanisms or bundled payments for inpatient stays.\5\ Current models
build upon early tests by examining condition-specific or acute
inpatient/outpatient episodes with accountability usually extending 90-
days beyond the triggering event. Generally, these episode-based
payment models have demonstrated reductions in gross Medicare spending,
driven in large part by reductions in post-acute care (PAC) spending or
utilization, with minimal to no change on quality of care.\6\
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\5\ The Medicare Hospital Gainsharing Demonstration (<a href="https://innovation.cms.gov/innovation-models/medicare-hospital-gainsharing">https://innovation.cms.gov/innovation-models/medicare-hospital-gainsharing</a>)
and Physician Hospital Collaboration Demonstration (<a href="https://innovation.cms.gov/innovation-models/physician-hospital-collaboration">https://innovation.cms.gov/innovation-models/physician-hospital-collaboration</a>) focused on gainsharing while the Medicare Acute Care
Episode Demonstration (<a href="https://innovation.cms.gov/innovation-models/ace">https://innovation.cms.gov/innovation-models/ace</a>) tested a global payment for certain inpatient stays.
\6\ Synthesis of Evaluation Results Across 21 Medicare Models
(<a href="https://innovation.cms.gov/data-and-reports/2022/wp-eval-synthesis-21models">https://innovation.cms.gov/data-and-reports/2022/wp-eval-synthesis-21models</a>).
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The Innovation Center is utilizing lessons learned from our
experience with the Bundled Payments for Care Improvement (BPCI),
Bundled Payments for Care Improvement Advanced (BPCI Advanced), and the
Comprehensive Care for Joint Replacement (CJR) models to design and
implement a new episode-based payment model focused on accountability
for quality and cost, health equity, and specialty integration. To
further inform development of the potential new model, we are
soliciting input from those with additional insight and frontline
experience with bundled payments. This request for information (RFI) is
not seeking feedback on models which address particular conditions over
a longer period of time, such as the Enhancing Oncology Model and the
Kidney Care Choices Model. Specifically, we are requesting input on a
broader set of questions related to care delivery and incentive
structure alignment and six foundational components:
<bullet> Clinical Episodes
<bullet> Participants
<bullet> Health Equity
<bullet> Quality Measures, Interoperability, and Multi-Payer Alignment
<bullet> Payment Methodology and Structure
<bullet> Model Overlap
In addition to maintaining or improving quality of care and
reducing Medicare spending (two requirements articulated in the
Innovation Center statute \7\), CMS intends to test an episode-based
payment model with goals to:
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\7\ Statutory requirements for CMS Innovation Center models are
covered in section 1115A of the Social Security Act.
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<bullet> Improve care transitions for the beneficiary; and
<bullet> Increase engagement of specialists within value-based,
accountable care.
We recognize that for these goals to be realized, there must be a
change in how episode-based payment models coexist with population-
based Medicare Accountable Care Organizations (ACOs). In theory, ACOs
and episode-based payment models should be complementary, as ACOs are
well situated to prevent unnecessary care, while episode-based payment
model participants focus on controlling the cost of acute, high-cost
episodes. However, these value-based care approaches have not
consistently been complementary and, in some cases, have complicated
health care operations.
The Innovation Center strategic refresh provides an opportunity to
better align episodes of care and population-based models to improve
the beneficiary experience and reduce health care inefficiencies.\8\
Furthermore,
[[Page 45874]]
coordination capitalizes on the strengths of each provider, allowing
them to manage and influence the outcomes that they control.
Unfortunately, the current ACO and episode-based payment environment
has created the perception that certain providers and suppliers are
striving for the same cost savings, and uncertainty with respect to who
manages a beneficiary's care. This issue is further exacerbated by
complex model overlap policies that have changed as models and
initiatives have evolved over time. These unintended consequences may
discourage providers from participating in alternative payment models
(APMs), leading to fewer beneficiaries under accountable care
relationships. In order for the Innovation Center to achieve its
strategic policy goals, episode-based payment incentives must be
aligned across models to encourage intentional overlap, promote
coordination, and facilitate seamless transition back to primary care.
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\8\ Ryan, A.M., Krinsky, S., Adler-Milstein, J., Damberg, C.L.,
Maurer, K.A., & Hollingsworth, J.M. (2017). Association Between
Hospitals' Engagement in Value-Based Reforms and Readmission
Reduction in the Hospital Readmission Reduction Program. JAMA
internal medicine, 177(6), 862-868. <a href="https://doi.org/10.1001/jamainternmed.2017.0518">https://doi.org/10.1001/jamainternmed.2017.0518</a>.
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II. Solicitation of Public Comments
The Centers for Medicare & Medicaid Services (CMS) Center for
Medicare and Medicaid Innovation (Innovation Center) seeks feedback
regarding a potential new episode-based payment model that would be
designed with a goal to improve beneficiary care and lower Medicare
expenditures by reducing fragmentation and increasing care coordination
across health care settings. The Innovation Center is releasing this
request for information (RFI) to gather feedback on testing a new model
design, built on previous experience with episode-based payment models,
and to further the goals of improved outcomes and reduced Medicare
spending. Whenever possible, respondents are requested to draw their
responses from objective, empirical, and actionable evidence and to
cite this evidence within their responses.
We anticipate this model would require participation by certain
entities, such as Medicare providers or suppliers or both located in
certain geographic regions, to ensure that a broad and representative
group of beneficiaries and participants are included. Further,
requiring participation would also help to overcome voluntary model
challenges such as clinical episode selection bias and participant
attrition. Therefore, any such model would be implemented via notice
and comment rulemaking, with ample opportunity for public input. We
expect this episode-based payment model to be implemented no earlier
than 2026, ensuring participants have sufficient time to prepare for
the model.
A. Care Delivery and Incentive Structure Alignment
Interested parties and experts have requested that CMS align
specialty care incentives with population-based model initiatives to
improve coordination across the continuum of care.\9\ In November 2022,
the Innovation Center released its comprehensive specialty strategy to
test models and innovations supporting access to high-quality,
integrated specialty care across the patient journey--both
longitudinally and for procedural or acute services.\10\ One element of
the strategy is to maintain momentum established by episode-based
payment models.
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\9\ Care coordination is a key concept for episode-based and
population-based initiatives. Please see the CMS Innovation Center's
Care Coordination page (<a href="https://innovation.cms.gov/key-concept/care-coordination">https://innovation.cms.gov/key-concept/care-coordination</a>) for further details.
\10\ The CMS Innovation Center's Strategy to Support Person-
centered, Value-based Specialty Care (<a href="https://www.cms.gov/blog/cms-innovation-centers-strategy-support-person-centered-value-based-specialty-care">https://www.cms.gov/blog/cms-innovation-centers-strategy-support-person-centered-value-based-specialty-care</a>).
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To date, the Innovation Center's episode-based payment models have
focused largely on acute inpatient and hospital outpatient episodes,
through CJR, BPCI, and BPCI Advanced. These model tests have
successfully driven essential care delivery changes to transform how
patients transition between hospitals and post-acute care
providers.\11\ Through this next model, CMS will build on those care
improvements to better align episodic and longitudinal, population-
based incentives, thereby strengthening communication, collaboration,
and coordination across providers at all points of a patient's journey
through the health care system. This will be achieved through design
features such as considering a shorter, 30-day episode to support
coordination, while limiting overlap.
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\11\ Comprehensive Care for Joint Replacement Model: Fourth
Evaluation Report (<a href="https://innovation.cms.gov/data-and-reports/2021/cjr-py4-annual-report">https://innovation.cms.gov/data-and-reports/2021/cjr-py4-annual-report</a>); BPCI Advanced: Fourth Annual Report (<a href="https://innovation.cms.gov/data-and-reports/2023/bpci-adv-ar4">https://innovation.cms.gov/data-and-reports/2023/bpci-adv-ar4</a>).
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To maintain momentum among providers and health systems, CMS
extended the original CJR model for an additional 3 performance years
(October 1, 2021-December 31, 2024), with modifications to certain
elements such as the episode definition and the payment methodology.
Subsequently, CMS extended BPCI Advanced for 2 years (January 1, 2024-
December 31, 2025), with technical changes to the pricing methodology
to balance participation incentives with statutory requirements. The
extension requires new convener participants to be Medicare-enrolled
providers or suppliers or ACOs, which will support increasing ACO
management of specialty conditions and primary care integration. In
addition, the future data transparency initiatives of the specialty
strategy will provide ACOs tools to better manage specialty care for
patients within their population.\12\
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\12\ CMS has signaled its intent to provide data on specialist
performance, such as shadow bundles, to facilitate integration with
ACOs. Shadow bundles would use existing ACO-attributed lives and
claims data to assign services and associated payments to clinical
episodes and enable a more nuanced view of performance on procedural
or condition specific care.
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The Innovation Center acknowledges that the role of clinical
episodes will grow and evolve as more patients are cared for by
providers in accountable care arrangements. To help us ensure all
accountable entities provide patients with the highest value care, we
seek input on the following questions:
<bullet> How can CMS structure episodes of care to increase
specialty and primary care integration and improve patient experience
and clinical outcomes?
<bullet> How can CMS support providers who may be required to
participate in this episode-based payment model?
<bullet> How can CMS ensure patient choice and rights will not be
compromised as they transition between health care settings and
providers?
<bullet> How can CMS promote person-centered care in episodes,
which includes mental health, behavioral health, and non-medical
determinants of health?
<bullet> How can CMS support multi-payer alignment for providers
and suppliers in episode-based and population-based models?
<bullet> For population-based entities currently engaging
specialists in episodic care management, what are the key factors
driving improvements in cost, quality, and outcomes?
<bullet> How does the nature of the relationship (that is,
employment, affiliation, etc.) between a population-based entity and a
specialist influence integration?
<bullet> What should CMS consider in the design of this model to
effectively incorporate health information technology (health IT)
standards and functionality, including interoperability, to support the
aims of the model?
<bullet> How can CMS include home and community-based interventions
during episode care transitions that provide connections to primary
care or behavioral health and support patient independence in home and
community settings? \13\
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\13\ For example, Community Aging In Place, Advancing Better
Living for Elders (CAPABLE) was a CMS Health Care Innovation Award
project (<a href="https://downloads.cms.gov/files/cmmi/hcia-chspt-thirdannualrpt.pdf">https://downloads.cms.gov/files/cmmi/hcia-chspt-thirdannualrpt.pdf</a>) that supported home-based care management by a
registered nurse and occupational therapy to improve functional
status. Services included home safety assessments, education,
problem solving, care coordination, and handyman services to address
housing-related safety risks.
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[[Page 45875]]
B. Clinical Episodes
The CJR and BPCI Advanced models test condition-specific medical or
surgical episodes, or both, which are initiated by either an inpatient
hospitalization or a hospital outpatient procedure and include items
and services provided over the following 90-day period.\14\
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\14\ Medical episodes are those requiring medical management of
an acute exacerbation of a condition whereas surgical episodes are
those requiring a procedural intervention.
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Many factors, including Medicare savings potential, are considered
when deciding which clinical episode categories a model will test.
Currently, there is no single clinical episode or service line group
that meets every priority, but each is considered against the following
criteria.
<bullet> Clinical homogeneity: Episodes with high clinical
homogeneity may simplify target price methodology and make it easier to
identify included items and services.
<bullet> Spending variability: Episodes with greater spending
variability suggest opportunities for reducing costs and improving
health care efficiency.
<bullet> Episode volume: Episodes with sufficient volume reduce
pricing volatility and may spread financial risk.
<bullet> Quality impacts: Episodes with established quality
measures or positive health equity outcomes may improve beneficiary
quality of care.
<bullet> Episode overlap alignment: Episodes that support ACO
collaboration.
CJR tests a single surgical episode category, while BPCI Advanced
includes 34 medical and surgical episode categories. Beginning in 2021,
the BPCI Advanced model combined the individual clinical episodes into
eight service line groups to expand participant accountability and
promote efficiencies across similar episodes. While participants
acknowledged the potential benefits of this change for increasing
episode volume, they highlighted the difficulties of redesigning care
processes across certain medical and critical care service lines. They
found identifying and implementing care redesign interventions to be
more straightforward for surgical episodes. CMS' BPCI Advanced
evaluation reflected this; reductions in episode payments were more
substantial for surgical episodes compared to medical episodes \15\ and
suggest early management may reduce Medicare spending.
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\15\ In the BPCI Advanced: Fourth Annual Report (<a href="https://innovation.cms.gov/data-and-reports/2023/bpci-adv-ar4">https://innovation.cms.gov/data-and-reports/2023/bpci-adv-ar4</a>), the
reduction in per-episode payments was larger for surgical clinical
episodes than medical clinical episodes (-$796 or -3.1 percent for
medical clinical episodes vs. -$1,800 or -5.8 percent for surgical
clinical episodes).
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CMS maximizes the items and services included in a clinical episode
to align with a total cost-of-care approach and ensure providers have
accountability for all related aspects of care. This total cost-of-care
approach represents an opportunity for improved care coordination and
collaboration across disciplines and settings. For example,
participants are generally accountable for the anchor event, along with
PAC, hospital readmissions, physician, laboratory, and durable medical
equipment costs.\16\ Although exclusion lists omit items and services
that are clearly unrelated to the anchor event, clinical subjectivity
does exist, and participants have expressed concern that they have
limited influence over some included items and services.
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\16\ Items and services typically included in a clinical episode
include inpatient/outpatient hospital services, post-acute care
services, laboratory services, durable medical equipment, Medicare
Part B drugs, physician services, and mental health services. Items
and services typically excluded from a clinical episode include
certain readmissions (for example, transplant or cancer), blood
clotting factors, new technology addon payments, and transitional
pass-through payments.
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The 90-day episode length has demonstrated success in reducing PAC
spending, but the extended duration of overlap between episode-based
payment models and ACO initiatives may contribute to inefficiencies.
Reducing episode duration to 30 days could both sustain the spending
reductions and mitigate some of the current challenges. Specifically, a
30-day episode would position the specialist as the principal provider
near the anchor event with a hand off back to the primary care provider
for longitudinal care management.
We anticipate this next episode-based payment model would test a
set of clinical episodes that is broader than CJR, but narrower than
BPCI Advanced, with shorter episode lengths. We request feedback on the
following clinical episode questions:
<bullet> Which of the clinical episode categories, tested in either
BPCI Advanced or CJR, should be considered for, or excluded from, this
next episode-based payment model? \17\
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\17\ The CJR model only tests the lower extremity for joint
replacement episode, which includes MS-DRGs 469, 470, 521, 522 and
CPT codes 27447 and 27130. The BPCI Advanced model tests 34 clinical
episode categories which can be found here: <a href="https://innovation.cms.gov/media/document/bpci-adv-clin-ep-lists-my6-mar2023">https://innovation.cms.gov/media/document/bpci-adv-clin-ep-lists-my6-mar2023</a>.
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<bullet> Should CMS test new clinical episode categories?
<bullet> How many clinical episode categories or service line
groupings should be tested?
<bullet> Should CMS consider alternatives to a 30-day episode
length? If so, include evidence to support this marker as the most
appropriate transition point from the hospital to the primary care
provider.
<bullet> Which clinical episodes are most appropriate for
collaboration between episode-based model participants and ACOs?
<bullet> Are there particular types of items or services that
should be excluded from clinical episodes?
<bullet> Are there other considerations for selection criteria that
are of interest to other payers?
<bullet> Aside from episode selection,reducing the duration of an
episode of care, and the types of services in an episode, what other
ways can CMS prevent unnecessary overlap with ACO functions?
<bullet> For which clinical episodes are ACOs better positioned
than episode-based payment model participants to efficiently manage
care?
<bullet> Should different participants be accountable for different
clinical episodes? For example, if both hospitals and physician group
practices (PGPs) are participants in the episode-based payment model,
should hospitals be accountable for a certain clinical episode category
(for example, congestive heart failure) or a certain clinical episode
type (for example, medical episodes vs. surgical episodes) as compared
to PGPs?
C. Participants
A key component of any APM is defining model participants. For
episode-based payment models, the participant generally assumes
accountability for cost and quality performance. Often, the type and
setting of clinical episodes will dictate who is eligible to
participate. The ability to bear financial risk, availability of
resources, prior value-based care experience, and downstream entities
may inform participant eligibility. Participant eligibility differed
between BPCI Advanced and CJR, and other entities have also expressed
interest in being participants in future episode-based payment models.
[[Page 45876]]
1. BPCI Advanced Participants
The BPCI Advanced model has convener and non-convener participants.
A convener bears and apportions financial risk and facilitates
coordination among one or more ``downstream episode initiators.'' In
contrast, a non-convener participant bears financial risk only for
itself and does not have any downstream episode initiators. Non-
convener participants and downstream episode initiators must be either
an acute care hospital or PGP.
Convener participants have generally been the dominant participant
type in BPCI Advanced. Conveners provide support such as analytics,
care navigators, and administrative assistance to their downstream
episode initiators, who otherwise may not have joined the model.
However, this arrangement was challenging for some hospitals and PGPs
participating as downstream episode initiators as they were removed
from decision-making, including when to exit the model. Further,
convener participants are required to have financial guarantees that
can impose significant upfront financial investment for participation.
2. CJR Participants
The participant structure of the CJR model is more straightforward
than BPCI Advanced. Acute care hospitals in select metropolitan
statistical areas are the only participants to trigger an episode and
be held accountable for cost and quality performance. When CJR was
implemented in 2016, we believed that the best policy approach was to
assign financial accountability to large entities, such as hospitals,
that care for a higher volume of Medicare beneficiaries. However, we
recognized the importance of smaller entities, such as PGPs, and
allowed gainsharing arrangements and other flexibilities to support
collaboration with participating CJR hospitals.
3. Other Entities
Aside from hospitals and PGPs, other providers have signaled
interest in managing or initiating clinical episodes. Expanding
provider or participant eligibility may increase model scope, but it
also adds operational complexity and reduces the likelihood of a
seamless care experience for the beneficiary. For this reason, CMS
attributes episodes to a single entity, regardless of the number of
providers involved. Precedence rules generally dictate to which entity
an episode of care is attributed, but these rules are often difficult
for participants to follow. Data feeds inform entities of episode
attribution when multiple providers have interacted with the
beneficiary, but participants still express challenges with identifying
their potential episodes due to lack of real-time data.
We request feedback on the following participant questions:
<bullet> Given that some entities may be better positioned to
assume financial risk, what considerations should CMS take into account
about different types of potential participants, such as hospitals and
PGPs?
++ Should CMS consider flexibilities for PGPs to participate, such
as a delayed start or a glide path to full financial risk?
++ How should CMS identify a PGP given the ability to form new
practices and obtain new Tax Identification Numbers, and given the
movement of suppliers within a PGP?
++ How can CMS ensure PGPs will remain engaged and accountable for
their contributions to managing the episode of care?
<bullet> What concerns are there with conveners not being formal
participants in this model since CMS cannot require entities that do
not particiate in the Medicare program? \18\
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\18\ Participants could still choose to partner with a convening
organization to receive similar services, such as data analytics or
care navigators.
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<bullet> Should CMS continue using precedence rules to attribute
clinical episodes to a single accountable entity or consider weighted
attribution for multiple accountable entities?
++ How could weighted attribution work?
++ How should incentives be structured to promote shared
accountability and ensure program integrity?
D. Health Equity
Health equity is a pillar of the Biden Administration, as mentioned
in Executive Order (E.O.) 13985, the HHS 2022-2026 Strategic Plan, and
the CMS 2022 Strategic Plan, and it is one of the five objectives in
the Innovation Center's 2021 Strategy Refresh.\19\ BPCI Advanced and
CJR were designed prior to this more intentional focus on equity, but
both models allow safety-net hospital participation and incorporate
risk adjustment for dually eligible beneficiaries. We recognize there
is room for improvement and intend to advance health equity through the
design, implementation, and evaluation of this next episode-based
payment model.
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\19\ CMS Innovation Center Strategic Direction (<a href="https://innovation.cms.gov/strategic-direction">https://innovation.cms.gov/strategic-direction</a>) and CMS Strategic Plan
(<a href="https://www.cms.gov/cms-strategic-plan">https://www.cms.gov/cms-strategic-plan</a>).
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The CJR 5th Annual Report and several independent studies display a
widening, statistically significant gap between lower extremity joint
replacement (LEJR) rates between the control group and CJR episodes and
beneficiaries who are Black/African American and those who are
white.<SUP>20 21 22 23</SUP> While CJR potentially had an unfavorable
impact on LEJR utilization rate, these studies acknowledge the presence
of pre-existing disparities before the implementation of the CJR model.
Future evaluations will capture the recent changes to the CJR risk
adjustment methodology to include beneficiaries who are dually-eligible
and the inclusion of safety-net hospitals. The impacts of these changes
will inform the development and use of future risk adjustment
strategies in episode-based models.
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\20\ CJR Fifth Annual Report (<a href="https://innovation.cms.gov/data-and-reports/2023/cjr-py5-annual-report">https://innovation.cms.gov/data-and-reports/2023/cjr-py5-annual-report</a>).
\21\ Thirukumaran, C.P., Yeunkyung, K., Cai, X., C., Ricciardi,
B.F., Yue, L., Fiscella, K.A., Mesfin, A., & Glance, L.G. (2021).
Association of the Comprehensive Care for Joint Replacement Model
with Disparities in the Use of Total Hip and Total Knee Replacement.
JAMA Network Open, 4 (5), e2111858.
\22\ Ko, H., Martin, B.I., Nelson, R.E., & Pelt, C.E. (2022).
Patient Selection in the Comprehensive Care for Joint Replacement
Model. Health Services Research, 57, 72-90.
\23\ Kim, H., Meath, T.H.A., Qui[ntilde]ones, A.R., McConnell,
K.J., & Ibrahim, S.A. (2021). Association of Medicare Mandatory
Bundled Payment Program with the Receipt of Elective Hip and Knee
Replacement in White, Black, and Hispanic Beneficiaries. JAMA
Network Open, 4 (3), e211772.
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Improving access to high-quality, patient-centered care is a goal
for the Innovation Center, and ensuring underserved beneficiaries are
adequately represented in value-based care models may help reduce
inequities when designed with the proper incentives. The BPCI Advanced
Model's 4th Annual Report provides evidence that medical episodes may
have greater reach to underserved populations than surgical episodes,
because underserved populations are more likely to be admitted to a
hospital due to a medical condition than due to a surgery.\24\
Therefore, medical episodes may provide a greater opportunity to reach
underserved beneficiaries in episode-based payment models, and by
extension decrease discrepancies in care.
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\24\ BPCI Advanced's 4th Annual Report (<a href="https://innovation.cms.gov/data-and-reports/2023/bpci-adv-ar4">https://innovation.cms.gov/data-and-reports/2023/bpci-adv-ar4</a>) covers health
equity findings from 2020-2021.
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The Innovation Center is also committed to prioritizing the unique
[[Page 45877]]
needs of providers who care for a large proportion of underserved
populations. This includes flexibilities providers may need to be
successful in future models. Further, to help address the increased
social needs of underserved populations, future episode-based payment
models will need to consider the use of area level indicators, such as
the social deprivation index (SDI), the social vulnerability index
(SVI), and the area deprivation index (ADI).\25\ These indicators would
not only help address the increased social needs of beneficiaries, but
would also help determine if additional risk adjustment variables would
increase future models' reach to underserved groups.
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\25\ Refer to Table 2.1 in the Landscape of Area-Level
Deprivation Measures and Other Approaches to Account for Social Risk
and Social Determinants of Health in Health Care Payments document
(<a href="https://aspe.hhs.gov/sites/default/files/documents/ce8cdc5da7d1b92314eab263a06efd03/Area-Level-SDOH-Indices-Report.pdf">https://aspe.hhs.gov/sites/default/files/documents/ce8cdc5da7d1b92314eab263a06efd03/Area-Level-SDOH-Indices-Report.pdf</a>)
for descriptions of ADI, SDI, and SVI.
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To illuminate the potential health equity impacts of a new episode-
based payment model and to help ensure the goals laid out in the CMS
Strategic Plan and the Innovation Center Strategy Refresh are met, we
request feedback on the following questions:
<bullet> What risk adjustments should be made to financial
benchmarks to account for higher costs of traditionally underserved
populations and safety net hospitals? (Quality measurement is addressed
more thoroughly in the next section of this RFI.)
<bullet> Should episode-based payment models employ special
adjustments or flexibilities for disproportionate share hospitals,
providers serving a greater proportion of dually eligible
beneficiaries, and/or providers in regions identified with a high ADI,
SVI, or SDI?
<bullet> What other factors could be considered for providers who
serve underserved beneficiaries or beneficiaries who experience social
risk factors? Can measure stratification among patient subgroups and
composite health equity measures improve how CMS identifies and
quantifies potential disparities in care and outcomes?
<bullet> Based on the BPCI Advanced 4th Annual Report findings and
the increased reach of medical episodes for underserved populations,
should the next episode-based payment model have a larger focus on
medical or surgical episodes?
<bullet> What metrics should be used or monitored to adjust payment
to assure health disparities are not worsened as an unintended
consequence?
<bullet> Aside from claims data, what data sources would be
valuable for evaluation and tracking of health equity?
++ What data or metrics or both should we share with participants
to ensure they are addressing gaps in clinical outcomes and access to
appropriate procedural care and with what frequency?
++ What data or metrics or both should we share publicly to help
inform beneficiaries of provider performance?
<bullet> What provider-level initiatives or interventions, such as
shared decision-making, could be considered to ensure equitable access
to procedures and treatments for beneficiaries?
E. Quality Measures and Multi-Payer Alignment
In accordance with section 1115A of the Social Security Act (the
Act), the Innovation Center tests models that are expected to improve
or maintain quality of care while reducing or maintaining program
expenditures.\26\ Current and prior models have used a combination of
claims data, participant-reported or registry-based quality measures,
and patient-reported outcome (PRO) measures to incentivize improvement
and assess model and participant performance. To reduce provider
burden, the Innovation Center is focused on including multi-payer
alignment approaches, where feasible.
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\26\ Section 1115A of the Social Security Act (<a href="https://www.ssa.gov/OP_Home/ssact/title11/1115A.htm">https://www.ssa.gov/OP_Home/ssact/title11/1115A.htm</a>).
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The CJR model assesses participant hospitals on a composite quality
score, which is based on the Hospital-Level Risk-Standardized
Complication Rate Following Elective Primary Total Hip Arthroplasty
and/or Total Knee Arthroplasty measure (CBE #1550 \27\), the Hospital
Consumer Assessment of Healthcare Providers and Systems (CAHPS[supreg])
Survey measure (CBE #0166), and voluntary total knee and total hip
arthroplasty PRO submission.
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\27\ In previous years, we referred to the consensus-based
entity (CBE) by corporate name. We have updated this language to
refer to the consensus-based entity more generally. See footnote 166
of the FY 2024 inpatient prospective payment systems (IPPS)/long-
term care hospitals (LTCH) prospective payment system (PPS) proposed
rule (88 FR 27025) (<a href="https://www.federalregister.gov/documents/2023/05/01/2023-07389/medicare-program-proposed-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals">https://www.federalregister.gov/documents/2023/05/01/2023-07389/medicare-program-proposed-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals</a>).
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The BPCI Advanced model relies on care coordination across settings
to improve quality and reduce costs for certain clinical episodes.
Participants can choose to report a maximum of 5 measures under either
the Administrative Quality Measure Set or Alternate Quality Measure
Set. The Administrative Quality Measure set uses claims-based measures,
including 3 required measures--Hospital-Wide All-Cause Unplanned
Readmission Measure (CBE #1789), Advance Care Plan (CBE #0326), and CMS
Patient Safety Indicators PSI 90 (CBE #0531)--and 3 additional measures
which are appropriate for certain episodes. The Alternate Quality
Measure Set requires reporting on the Hospital-Wide All-Cause Unplanned
Readmission Measure (CBE #1789) and Advance Care Plan (CBE #0326)
measures, and includes 23 more clinically-aligned measures appropriate
for specific episodes. These measures are derived from registries and
inpatient quality reporting, as well as claims.
The Innovation Center recently conducted a review of 21 Medicare
models implemented between 2012 and 2020.\28\ The evaluation, which
examined relative performance on costs and quality, found two-thirds of
the models demonstrated significant gross savings, but most showed no
significant improvement in patient experience or mortality. Notably,
the CJR model and surgical episodes managed by PGPs in the BPCI
Advanced model significantly decreased readmissions, although neither
model showed improvement in patient experience or reductions in
emergency department use. The heterogeneity of quality measures used
across models made relative assessment difficult and limited comparison
to a handful of metrics for a subset of models. For example, self-
reported experience of care was only measured in 12 of the 21 models.
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\28\ The Synthesis of Evaluation Results Across 21 Medicare
Models (<a href="https://innovation.cms.gov/data-and-reports/2022/wp-eval-synthesis-21models">https://innovation.cms.gov/data-and-reports/2022/wp-eval-synthesis-21models</a>) highlighted that decreases in spending were most
significant among acute and specialty care models, largely driven by
lower utilization--5 models reduced emergency department (ED) visits
and 8 reduced inpatient readmissions.
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CMS is committed to improving alignment across models and programs
to simplify relative comparison of quality performance, to effectively
track quality, outcomes, patient experience, and interoperable exchange
of care data to generate evidence for determining whether, and to what
extent, individual models improve care quality. This is in line with
the broader CMS National Quality Strategy, including an effort to move
toward digital quality measurement,\29\ and recently announced plans to
employ a ``Universal Foundation'' of quality measures to create greater
consistency
[[Page 45878]]
in primary care quality reporting.\30\ As an extension of that aim, and
with a particular focus on specialty care, the Innovation Center is
considering how to increase the use of model-specific measures and
adopt a more person-centered quality strategy, including greater use of
PRO measures.
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\29\ dQM Strategic Roadmap (<a href="https://ecqi.healthit.gov/dqm">https://ecqi.healthit.gov/dqm</a>).
\30\ Jacobs, D.B., Schreiber, M., Seshamani, M., Tsai, D.,
Fowler, E., & Fleisher, L.A. (2023). Aligning Quality Measures
across CMS--The Universal Foundation. New England Journal of
Medicine, 388 (9), 776-779. DOI: 10.1056/NEJMp2215539.
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To that end, we are seeking feedback on how to best align quality
measurement between new and established models and across payers, how
other payers have approached quality measurement in episode-based
models, and potential areas of alignment for a future episode-based
payment model.
<bullet> Which quality measures, currently used in established
models or quality reporting programs, would be most valuable for use
across care settings?
<bullet> What quality measures are other payers using to drive
improvements in clinical episodes?
<bullet> What PRO measures should CMS consider including in this
next episode-based payment model?
++ Are payers testing or finding success with any PRO measures in
existing episode-based models?
<bullet> In what specific measurement areas can CMS improve upon
the current Inpatient Quality Reporting and Value-Based Purchasing
measure sets \31\ to better capture performance on acute medical and
surgical episodes and the interoperable exchange of patient data
between coordinating providers?
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\31\ The Acute Care Hospital Quality Improvement Program
Measures FY 2025 reference guide (<a href="https://qualitynet.cms.gov/inpatient/iqr/measures">https://qualitynet.cms.gov/inpatient/iqr/measures</a>) provides a comparison of measures for five
CMS acute care hospital quality improvement programs.
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<bullet> The CAHPS[supreg] for the Merit-based Incentive Payment
System (MIPS) includes questions to assess the degree to which shared
decision-making has been implemented in the outpatient setting. How can
CMS most effectively measure these activities in the hospital setting?
<bullet> What supports can this new model provide for decreasing
burden of data collection?
++ How can registries, electronic health records, and other quality
reporting systems reduce reporting burden for participants?
++ What approaches are providers currently utilizing that would
create opportunities for payer alignment?
++ Are there opportunities to reduce provider burden across
episodes through multi-payer alignment of quality measures and social
risk adjustment?
F. Payment Methodology and Structure
Payment methodology is a key element of an episode-based payment
model. While there are notable differences between the CJR and BPCI
Advanced payment methodologies, the models are built on a similar
underlying payment structure wherein participants receive preliminary
target prices prior to the performance period, are paid through the
traditional Medicare FFS payment systems during a performance period,
and are subject to a retrospective payment reconciliation calculation
after the performance period. This reconciliation calculation compares
the participant's FFS spending to an adjusted target price, with the
participant either earning a reconciliation payment or owing a
repayment to Medicare. This retrospective reconciliation process avoids
the need for changes to Medicare FFS claims-processing systems and for
participants to pay downstream providers who deliver services during
the episode, as is done with prospective model payments. However, both
models have been subject to challenges with regard to various aspects
of the payment methodology, including reconciliation timing, target
price methodology, and risk adjustment.
1. Reconciliation Timing
CMS has tried to balance participants' desire to receive
reconciliation results as close as possible to the performance period,
while also allowing for sufficient claims runout to finalize the
results and minimize the administrative burden of multiple
reconciliations. Still, participants have indicated difficulty
investing in and maintaining care redesign activities, as the incentive
payments that support these activities are paid well after they have
occurred. Reconciliation timing for BPCI Advanced, CJR, and the CJR
extension are summarized in Table 1.
Table 1--Comparison of Reconciliation Timing
----------------------------------------------------------------------------------------------------------------
BPCI Advanced model CJR performance years
years (MYs) 1-8 (PYs) 1-5 CJR extension PYs 6-8
----------------------------------------------------------------------------------------------------------------
Performance Period................. 6 months.............. 1 year \32\........... 1 year.\33\
Number of Reconciliations per 3..................... 2..................... 1.
Performance Period.
Approximate Claims Runout (from 3 months, 9 months, 15 2 months, 14 months... 6 months.
last episode). months.
----------------------------------------------------------------------------------------------------------------
2. Target Prices
Reconciliations are based on comparison of performance period
spending and the target price for a given participant and episode. The
method of calculating target prices has changed over time for both CJR
and BPCI Advanced, as CMS has sought to balance the need for
predictable and achievable target prices with the need to respond to
market changes and allow a reasonable likelihood of overall Medicare
savings. Key features of the target price methodology for BPCI
Advanced, CJR, and the CJR extension are summarized in Table 2.
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\32\ With the exception of years impacted by COVID.
\33\ With the exception of years impacted by COVID.
Table 2--Comparison of Target Pricing
----------------------------------------------------------------------------------------------------------------
BPCI Advanced (MYs BPCI Advanced (MYs CJR extension (PY
1-3) 4-8) CJR (PY 1-5) 6-8)
----------------------------------------------------------------------------------------------------------------
Baseline Claims Period.......... 4 years........... 4 years........... 3 years........... 1 year.
Frequency of Baseline Update.... Annual............ Annual............ Every 2 years..... Annual.\34\
[[Page 45879]]
Baseline Claims Blend........... Participant Participant PY 1-2: \2/3\ Regional Only.
Historical Historical Participant, \1/
Claims, Patient Claims, Patient 3\ Regional. PY
Case Mix, Peer Case Mix, Peer 3: \1/3\
Group Group Participant, \2/
Characteristics, Characteristics, 3\ Regional. PY 4-
Peer Group Trends. Peer Group Trends. 5: Regional Only.
Adjustments at Reconciliation... Patient Case Mix Patient Case Mix Quality Adjustment Regional Market
Adjustment, Adjustment, Peer Trend Factor,
Quality Group Trend Normalization
Adjustment. Factor Factor, Quality
Adjustment, Adjustment.
Quality
Adjustment.
----------------------------------------------------------------------------------------------------------------
The CJR and BPCI Advanced models initially used a prospective trend
methodology to project future episode spending to construct target
prices. However, early reconciliation results from both models,
combined with nationwide spending data, suggested that the prospective
trend had not accurately captured national changes in spending patterns
during the model performance period, resulting in reconciliation
payments that were higher than needed to incentivize care coordination.
To more accurately reflect performance period episode costs and to help
minimize the risk that the models increased spending, CMS incorporated
a retrospective trend into the target price methodology for both
models, allowing for a target price adjustment at reconciliation.\35\
However, a number of BPCI Advanced participants found the retrospective
trend untenable, given the unpredictability and resulting challenge of
gauging their performance in the model. The retrospective trend for
most episodes was lower than the prospective trend had been in previous
years, resulting in a downward adjustment to target prices at
reconciliation and leading many participants to withdraw from the
model.
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\34\ With the exception of PY 7, which repeated the use of 2019
data as baseline in order to avoid the impact of COVID in 2020 data.
\35\ Under section 1115A(b)(3)(B) of the Social Security Act,
the CMS Innovation Center has a statutory obligation to modify or
terminate models unless the model is expected to improve quality
without increasing spending, reduce spending without reducing
quality, or improve quality and reduce spending after testing has
begun.
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3. Risk Adjustment
CMS recognizes that patients will require various levels of care,
with differences in appropriate episode spending based on a number of
factors. To acknowledge this variability and minimize the likelihood of
participants preferentially selecting healthier patients for treatment
in the model (also known as ``cherry picking''), CMS has included risk
adjustment in both the CJR and BPCI Advanced payment methodologies.
Factors used in risk adjustment are summarized in Table 3.
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\36\ While the patient characteristics used in risk adjustment
has remained fairly consistent across Model Years, please see the
BPCI Advanced Model Year 6 Target Prices Specifications (<a href="https://innovation.cms.gov/media/document/bpci-adv-targetprice-specs-my6-mar2023">https://innovation.cms.gov/media/document/bpci-adv-targetprice-specs-my6-mar2023</a>) for the most updated and complete list.
\37\ Medicare Severity Diagnosis Related Group/Ambulatory
Payment Classifications.
\38\ The FY 2021 IPPS/LTCH final rule (85 FR 58432) created two
new MS-DRGs that separated hospital discharges for LEJR with hip
fracture (521, 522) from those without hip fracture (469, 470). CJR
added these MS-DRGs to the model, which removed the need for an
additional risk adjustment for hip fracture.
\39\ Medicare Severity Diagnosis Related Group/Healthcare Common
Procedure Coding System.
Table 3--Comparison of Patient-Level Risk Adjustment Factors
------------------------------------------------------------------------
CJR extension (PY
BPCI Advanced (MY 1-8) \36\ CJR (PY 1-5) 6-8)
------------------------------------------------------------------------
MS-DRG/APCs,\37\ age, dual MS-DRG, hip MS-DRG/HCPCS,\39\
eligibility status, disability fracture \38\. age group, dual
as reason for Medicare eligibility
eligibility, Hierarchical status, CJR HCC
Condition Categories (HCCs), count.
HCC count, recent health
service resource use.
------------------------------------------------------------------------
Risk adjustment in Innovation Center episode-based models is
largely based on CMS claims and enrollment data. However, beneficiary
characteristics from other sources, such as electronic health records
or non-medical determinants of health, are not accounted for by the use
of claims and enrollment data. CMS is considering ways to incorporate
non-claims-based variables, if collected uniformly and documented
consistently, to improve risk adjustment and address health equity.
Interested parties have also recommended the inclusion of trigger event
diagnosis codes to better capture beneficiary acuity. However, we are
concerned that risk adjusting based on variables that occur
contemporaneous to the episode could incentivize increased coding
intensity.
4. Alternative Payment Approach
In light of the CJR and BPCI Advanced payment methodology
challenges, we are considering changes to our payment approach, such as
incorporating elements of value-based purchasing. Under a value-based
purchasing framework, participants are assessed on certain measures and
their future Medicare FFS payments are adjusted up or down based on
their performance. For instance, the Hospital Value Based Purchasing
(VBP) program withholds 2% of the base operating MS-DRG payments of
participating hospitals, and then redistributes those funds to
hospitals in a future year via a payment adjustment based on their
Total Performance Score across four domains (Clinical Outcomes, Person
and Community Engagement, Safety, and Efficiency and Cost Reduction).
Similarly, in the traditional Merit-based Incentive Payment System
(MIPS), clinicians submit data on four domains (Quality, Promoting
Interoperability, Improvement Activities, and Cost), and the MIPS final
score determines a payment adjustment to future Medicare Part B claims.
To avoid duplicating the existing value-based purchasing initiatives,
we are considering blending the traditional payment approach by setting
a target price but paying the reconciliation payment (or recouping the
repayment amount) in future years as a multiplier or add-on to future
[[Page 45880]]
claims, rather than as a lump sum at the time of the reconciliation
calculation. We anticipate that incorporating value-based purchasing
design components could help to resolve concerns with pricing
predictability and remove the operational burdens of the reconciliation
process. We recognize this alternative approach, along with other
payment methodology features, would require input from interested
parties. Therefore, we request feedback on the following payment
methodology questions.
<bullet> How should CMS balance the need for predictable,
achievable target prices with the need to create a reasonable
possibility of achieving net Medicare savings?
<bullet> How should CMS balance participants' desire to receive
reconciliation results as close as possible to the performance period,
while also allowing for sufficient claims runout to finalize the
results and minimize the administrative burden of multiple
reconciliations?
<bullet> How should risk adjustment be factored into payment for
episode-based payment models?
++ How can risk adjustment be designed to guard against
preferential selection of healthier patients (that is, cherry picking)?
++ What risk factors, including clinical or social, should be
considered?
++ Which non-claims-based variables could be used to improve risk
adjustment and address health equity, and how can CMS ensure that they
are collected uniformly and documented consistently?
++ How can CMS account for apparent changes in risk that are
actually due to changes in coding patterns rather than changes in
health status?
<bullet> If CMS were to move toward a value-based purchasing
approach for acute care episodes, what performance measures (including
quality and utilization or cost measures) should participants be
accountable for?
++ What level of payment adjustment to future claims would be
sufficient to balance the need to: (1) incentivize coordination with
physician group practices and post-acute care providers; (2) achieve
savings or budget neutrality for Medicare; and (3) create a reasonable,
but not onerous, level of downside risk for participants?
++ To what extent could quality measures already collected in
existing value-based programs (for example, MIPS, MIPS Value Pathways
(MVPs), post-acute care VBPs) be incorporated into an acute care
episode-based payment model?
<bullet> How could CMS incorporate other non-claims-based
variables, such as from electronic health records or non-medical
determinants of health, to improve risk adjustment, care coordination,
quality measurement, and/or address health equity?
G. Model Overlap
The Innovation Center Strategic Refresh highlights the need to
streamline the Innovation Center's model portfolio, reduce complexity,
and capture broad provider participation.\40\ These lessons learned
resonate when considering the challenges between the interactions of
episode-based payment models and ACO initiatives. While CMS continues
to learn from tested policies, none have consistently encouraged
overlap or promoted meaningful collaboration between primary care and
specialty care providers. Overlap policies were intended to avoid
duplicative incentive payments or give precedence to a single
accountable entity. In some cases, these policies resulted in confusing
methodologies or misaligned incentives which were difficult for
providers to navigate. Providers have also cited confusion with
identifying to which model(s) a beneficiary may be aligned or
attributed.
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\40\ CMS White Paper on CMS Innovation Center's Strategy:
Driving Health System Transformation--A Strategy for the CMS
Innovation Center's Second Decade (<a href="https://innovation.cms.gov/strategic-direction">https://innovation.cms.gov/strategic-direction</a>-whitepaper).
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1. Duplicate Payments
In earlier episode-based payment models, such as CJR (when
applicable) and BPCI, CMS addressed overlap by implementing a complex
calculation and recouping a portion of the pricing discount for
providers participating in certain ACO initiatives. The recoupment was
intended to prevent duplicate incentive payments for the same
beneficiary's care. Yet some participants perceived the recoupment as a
financial penalty, discouraging providers from participating in both
initiatives. To avoid complexity, the CJR and BPCI Advanced models
exclude overlap for beneficiaries aligned or assigned to certain ACOs,
and these beneficiaries will not initiate a clinical episode.\41\
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\41\ Currently, the BPCI Advanced model does not allow overlap
with the ACO Realizing Equity, Access, and Community Health (ACO
REACH) model, the Vermont All-Payer ACO Model, and the Comprehensive
Kidney Care Contracting (CKCC) Options of the Kidney Care Choices
(KCC) Model. The CJR model does not allow overlap with the ENHANCED
Track of the Medicare Shared Savings Program.
---------------------------------------------------------------------------
While this exclusionary approach creates a clean demarcation of who
is accountable for a beneficiary's care, it also limits the number of
providers in accountable care relationships and becomes less tenable as
we work towards the goal of increased accountability. Additionally,
participants may be informed of beneficiary ACO alignment or assignment
after the potential episode has been initiated and after the
participant has expended resources for items or services not covered by
Medicare on unattributed beneficiaries. This concern highlights the
opportunity to incentivize coordinated care, expand care redesign
efforts to more patients, and strengthen APM participation. Lastly,
even passive avoidance of duplicate payments has its drawbacks such as
lack of incentive to coordinate care. For example, the CJR and BPCI
Advanced models allow overlap with the Medicare Shared Savings Program
without a financial recoupment.<SUP>42 43</SUP> However, this does not
encourage behavior change to ensure a smooth transition back to
population-based providers.
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\42\ The Medicare Shared Savings Program benchmark updates
include retrospective county-level trends that implicitly reflect
BPCI Advanced and CJR spending changes; such methodology helps
mitigate potential overlap of federal outlays.
\43\ The CJR model only allows overlap with the BASIC track of
the Medicare Shared Savings Program.
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2. Overlap
Both episode-based payment models and ACOs have demonstrated
successes in reducing post-acute care spending through reductions in
skilled nursing facility length of stay or reduced institutional post-
acute care use.<SUP>44 45</SUP> However, when the same beneficiary is
included in both an ACO initiative and episode-based payment model, it
may create confusion and inefficiencies. Providers in both models
invest in care management and rely on the savings generated to support
these functions. If those spending reductions are credited to only one
of these entities, this may create a barrier for collaboration.
Further, if an episode of care is priced too high, this can negatively
impact the ACO's financial performance and add to inefficiencies
between episode-based payment models and ACOs.
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\44\ Comprehensive Care for Joint Replacement Model: Fourth
Evaluation Report; BPCI Advanced: Fourth Annual Report (<a href="https://innovation.cms.gov/data-and-reports/2021/cjr-py4-annual-report">https://innovation.cms.gov/data-and-reports/2021/cjr-py4-annual-report</a>).
\45\ McWilliams, J.M., Gilstrap, L.G., Stevenson, D.G., Chernew,
M.E., Huskamp, H.A., & Grabowski, D.C. (2017). Changes in Postacute
Care in the Medicare Shared Savings Program. JAMA internal medicine,
177(4), 518-526. doi:10.1001/jamainternmed.2016.9115.
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Regardless of the issues identified, evidence suggests shared
beneficiaries in episode-based payment models and
[[Page 45881]]
ACOs can lead to lower post-acute care spending and reduced
readmissions.\46\ In light of findings like this, we believe overlap
with episode-based payment models and ACOs should be supported through
complementary policies. We want to avoid precedence or exclusionary
rules for entities who may be required to participate in this next
episode-based payment model. This means all of the participating
entity's beneficiaries for a given clinical episode or service line
group may be eligible to initiate an episode regardless of beneficiary
ACO assignment/alignment. This may help the participant create standard
care pathways for all beneficiaries and make it easier for ACOs to know
which beneficiaries may be initiating a clinical episode. We also want
to encourage overlap between this next model and ACO initiatives to
support coordination and ensure providers are not carved out of a
beneficiary's continuum of care. This means we must account for
duplicate payments when there are shared beneficiaries. We are
considering simple ways a target price can be factored into an ACO's
benchmark, or how the target price can be adjusted to account for
shared beneficiaries so that providers in both models have financial
incentives to drive efficiency and coordinate care. We aim to resolve
the previous model overlap challenges and request feedback for the
following model overlap questions:
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\46\ Navathe, A.S., Liao, J.M., Wang, E., Isidro, U., Zhu, J.,
Cousins, D.S., & Werner, R.M. (2021). Association of Patient
Outcomes With Bundled Payments Among Hospitalized Patients
Attributed to Accountable Care Organizations. JAMA health forum,
2(8), e212131. <a href="https://doi.org/10.1001/jamahealthforum.2021.2131">https://doi.org/10.1001/jamahealthforum.2021.2131</a>.
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<bullet> How can CMS allow beneficiary overlap with ACO initiatives
yet ensure Medicare is not double-paying incentives for the same
beneficiary?
++ Should the approach to prevent double-paying incentives differ
depending on whether the participating entity is part of an ACO or
particular type of ACO (for example, low revenue ACOs vs. high revenue
ACOs, or one-sided vs. two-sided risk ACOs)?
++ What are the implications of allowing beneficiary overlap for
model evaluation?
<bullet> How should CMS create a reciprocal overlap policy that
incentivizes efficiency by the participant while the ACO is
incentivized to use the participant for episodic care?
++ What risks or rewards should we include to drive collaboration?
++ What resources or data should CMS provide participants to ensure
there is collaboration with ACO providers for shared beneficiaries?
++ What resources or data should CMS provide ACOs to ensure
collaboration with participants for shared beneficiaries? How does this
differ when the participant is not part of the ACO?
<bullet> How can CMS leverage this episode-based payment model to
incentivize participants to join an ACO if not already a part of one?
++ Conversely, how can this episode-based payment model incentivize
ACOs to partner with participants?
<bullet> How does CMS ensure episode spending aligns with ACO
benchmarks, especially if ACO benchmark methodology changes?
<bullet> What levers, such as benefit enhancements or waivers,
could be used to support participants to close the care loop back to
primary care/ACOs?
<bullet> How can CMS design this model to spur ACOs to engage
specialty care providers for episodes of care that may not be included
in this model?
III. Collection of Information Requirements
Please note, this is a request for information (RFI) only. In
accordance with the implementing regulations of the Paperwork Reduction
Act of 1995 (PRA), specifically 5 CFR 1320.3(h)(4), this general
solicitation is exempt from the PRA. Facts or opinions submitted in
response to general solicitations of comments from the public,
published in the Federal Register or other publications, regardless of
the form or format thereof, provided that no person is required to
supply specific information pertaining to the commenter, other than
that necessary for self-identification, as a condition of the agency's
full consideration, are not generally considered information
collections and therefore not subject to the PRA.
We note that this is a RFI only. This RFI is issued solely for
information and planning purposes; it does not constitute a Request for
Proposal (RFP), applications, proposal abstracts, or quotations. This
RFI does not commit the U.S. Government to contract for any supplies or
services or make a grant award. Further, we are not seeking proposals
through this RFI and will not accept unsolicited proposals. Responders
are advised that the U.S. Government will not pay for any information
or administrative costs incurred in response to this RFI; all costs
associated with responding to this RFI will be solely at the interested
party's expense. We note that not responding to this RFI does not
preclude participation in any future procurement, if conducted. It is
the responsibility of the potential responders to monitor this RFI
announcement for additional information pertaining to this request. In
addition, we note that CMS will not respond to questions about the
policy issues raised in this RFI.
We will actively consider all input as we develop future regulatory
proposals or future subregulatory policy guidance. We may or may not
choose to contact individual responders. Such communications would be
for the sole purpose of clarifying statements in the responders'
written responses. Contractor support personnel may be used to review
responses to this RFI. Responses to this document are not offers and
cannot be accepted by the Government to form a binding contract or
issue a grant. Information obtained as a result of this RFI may be used
by the Government for program planning on a non-attribution basis.
Respondents should not include any information that might be considered
proprietary or confidential. This RFI should not be construed as a
commitment or authorization to incur cost for which reimbursement would
be required or sought. All submissions become U.S. Government property
and will not be returned. In addition, we may publicly post the public
comments received, or a summary of those public comments.
Chiquita Brooks-LaSure, Administrator of the Centers for Medicare &
Medicaid Services, approved this document on July 11, 2023.
Dated: July 13, 2023.
Xavier Becerra,
Secretary, Department of Health and Human Services.
[FR Doc. 2023-15169 Filed 7-14-23; 11:15 am]
BILLING CODE 4120-01-P
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