Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR): Final Rule Overview February 22, 2017
Presenters • Heather Holsey • Josiah Mueller • Rhya Ghose 2
Disclaimer This presentation was current at the time it was published or uploaded onto the web. Medicare policy • changes frequently, so links to the source documents have been provided within the document for your reference. This presentation was prepared as a service to the public and is not intended to grant rights or impose • obligations. This presentation may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations, and other interpretive materials for a full and accurate statement of their contents. 3
Today’s Agenda Request for hospital point of contact (POC) information Please send the following information to epmsupport@cms.hhs.gov Hospital CCN in Subject Line • Names of two primary points of contact for EPM communication • Titles, telephone numbers, and email addresses for POCs • Hospital Physical Mailing Address • Highlight major policy changes in final rule compared to proposed rule Overview of Advancing Care Coordination through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) final rule Slides will be available on our website https://innovation.cms.gov/initiatives/epm/ as soon as possible. 4
Proposed Rule to Final Rule The proposed rule was published on August 2, 2016, with the comment period ending October 3, 2016. After reviewing nearly 175 highly detailed comment submissions from the public on the proposed rule, and considering commenters’ thoughtful perspectives, several major changes were made from the proposed rule. On December 20, 2016, the final rule entitled: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR) went on display at the Federal Register. As directed by the White House memorandum of January 20, 2017 entitled “Regulatory Freeze Pending Review”, CMS is delaying the effective date of the provisions of the final rule, which were to become effective on February 18, until March 21 . The delay notice was published in the Federal Register on February 15, 2017. No other changes to the rule beyond the effective date delay are anticipated at this time. The full text of the rule is available now online and in PDF format at the following website: – https://www.federalregister.gov/documents/2017/01/03/2016- 30746/medicare-program-advancing-care-coordination-through-episode- payment-models-epms-cardiac. 5
EPM Final Rule Summary The Advancing Care Coordination Final rule implements three new Medicare Parts A and B episode payment models, in which acute care hospitals in certain selected geographic areas will receive retrospective bundled payments for episodes of care for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) and surgical hip and femur fracture treatment (SHFFT). The rule also implements a Cardiac Rehabilitation (CR) Incentive Payment model and makes modifications to the existing Comprehensive Care for Joint Replacement (CJR) model under section 1115A of the Social Security Act. The new CR Incentive Payment model will test incentive payments to increase utilization of CR services for AMI and CABG patients, both alongside the AMI and CABG EPMs as well as in conjunction with traditional fee for service (FFS) Medicare payments. The CJR model changes will clarify, modify and update certain provisions around target pricing, composite quality, and beneficiary incentives and exclusions. Additionally the final rule creates an option for CJR participant hospitals to be in an Advanced APM that would, in turn, allow eligible clinicians to be considered for a QP determination. 6
Major Policy Changes from the Proposed Rule In response to comments received on the proposed rule, CMS made the following changes to the final rule policies: Pricing and Payment • Downside risk will begin for all on October 1, 2018 instead of on April 1, 2018 which was the proposed date; The models now allow voluntary opt in to downside risk Jan 1, 2018 (to meet advanced APM requirements). A low-volume provider definition was created in response to comment and hospitals in this category will have the same lower stop-loss limits provided to rural hospitals in the model. Quality • Proposed quality measures were finalized with a modification to the proposed CABG measures to include data submission for the STS composite CABG measure as a voluntary measure worth 2 additional points toward the composite CABG quality score. 7
Major Policy Changes from the Proposed Rule • Transfers: We did not finalize the proposal for chained anchor hospitalization therefore the terms ‘chained anchor stay’ and ‘Price-DRG’ are not applicable for the final models. We now cancel AMI episodes that begin on inpatient admission to the initial treating hospital when any inpatient-to-inpatient transfer occurs. A new AMI or CABG episode begins at the transfer hospital if that transfer hospital is an AMI or CABG participant and the MS-DRG (and diagnosis) assigned at the transfer hospital meets the criteria for initiating an AMI or CABG episode. Begin episode and assign risk and clinical episode to final discharging hospital after any transfer (either from the emergency department or inpatient hospitalization at the initial treating hospital). 8
What Are the EPMs Designed To Do for Patients and the Health System? Better Care Better care for patients through more coordinated, higher quality care during and • after select episodes or care periods Smarter Spending Smarter spending of health care dollars by holding hospitals accountable for total • episode spending, not just inpatient costs, and incentivizing use of high value services during care periods Healthier People and Communities Healthier people and communities by improving coordination in health care and by • connecting care across hospitals, physicians, and other health care providers 9
EPM Participants AMI & CABG EPMs: Hospitals in 98 selected metropolitan statistical areas (MSAs), with limited exceptions. The MSAs were randomly selected from 29 3 eligible MSAs and presented in the final rule. SHFFT EPM: Hospitals in MSAs selected for the CJR model, with limited exceptions. Participant hospitals in these selected MSAs are all acute care hospitals paid under the IPPS that are not currently participating in Models 1, 2 or 4 of the Bundled Payments for Care Improvement (BPCI) Initiative. Current estimate is that over 2,000 hospitals will participate in the EPMs and CR Incentive Payment Model . Participant lists are available at the EPM website. https://innovation.cms.gov/initiatives/epm/ 10
Advanced APM Tracks In order to maximize the opportunities for eligible clinicians to participate in Advanced APMs, CMS finalized two tracks for each of the EPMs. Participants may switch between tracks during the 5 years the models run. Track 1 – Advanced APM Track Participant hospitals must meet and attest to the CEHRT use requirement, as specified in section 1833(z)(3)(D)(i)(I) of the Act Participants must submit a clinician financial arrangements list to CMS no more than quarterly Participation of eligible clinicians collaborating with Track 1 hospitals will count toward Advanced APM participation for purposes of the Quality Payment Program Track 2 – Non Advanced APM Track EPM participants that do not choose to meet and attest to the CEHRT use requirement will be in Track 2 11
What is an EPM Episode of Care? EPM episodes initiate with hospitalizations of eligible Medicare fee-for-service beneficiaries discharged with specified MS-DRGs: AMI (AMI MS-DRGs: 280-282 & PCI MS-DRGs: 246-251 with AMI ICD-CM diagnosis code) IPPS admissions for AMI treated medically or with revascularization via percutaneous coronary intervention (PCI) CABG (MS-DRGs: 231-236) IPPS admissions for surgical coronary revascularization irrespective of AMI diagnosis SHFFT (MS-DRGs: 480-482) IPPS admissions for hip/femur fracture fixation, other than joint replacement Episodes include: Hospitalization and 90 days post-discharge The day of discharge is counted as the first day of the 90-day post-discharge period. All Part A and Part B services, with the exception of certain excluded services that are clinically unrelated to the episode 12
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