New payment models proposed by CMS
Medicare & Medicaid Services (CMS) proposed new payment models that would reward hospitals for working together with healthcare providers to avoid, Complications, Prevent hospital re-admissions, and Speed recovery in patients admitted for cardiovascular disease or hip/femur fracture.
The notice of proposed rulemaking contains three new policies:
- New bundled payment models for cardiac care and an extension of the existing bundled payment model for hip replacements to other hip surgeries;
- A new model to increase cardiac rehabilitation; and
- A proposed pathway for physicians with significant participation in bundled payment models to qualify for payment incentives under the Quality Payment Program.
CMS proposes the first performance period to start July 1, 2017, and end December 31, 2017. Target prices would be based on a blend of hospital-specific data and regional historical data, as such:
- July 1, 2017 ? December 31, 2018: Two-thirds participant-specific data and one-third regional data
- 2019: One-third participant-specific data and two-thirds regional data
- 2020-2021: Regional data only
Downside risk would be phased in, as such:
- July 2017 ? March 2018: No repayment
- April 2018 ? December 2018: Capped at 5 percent
- 2019: Capped at 10 percent
- 2020-2021: Capped at 20 percent
Gains would be phased in, as such:
- July 2017 ? December 2018: Capped at 5 percent
- 2019: Capped at 10 percent
- 2020-2021: Capped at 20 percent
The new Cardiac Rehabilitation Incentive Payment Model will test the impact of providing an incentive payment to hospitals where beneficiaries are hospitalized for a heart attack or bypass surgery, which would be based on beneficiary utilization of cardiac rehab and intensive cardiac rehab services in the 90-day care period following hospital discharge.
Payments would be available to hospital participants in 45 geographic areas that were not selected for the cardiac care bundled payment models, as well as 45 geographic areas that were. The test will cover the same five-year period as the cardiac care bundled payment models. Standard Medicare payments for cardiac rehab services furnished to model beneficiaries would continue to be made directly to the providers.
The two-part cardiac rehab incentive payment would be paid retrospectively based on the total cardiac rehab use:
- The initial payment would be $25 per cardiac rehab service for each of the first 11 services paid for by Medicare during the care period for a heart attack or bypass surgery.
- After 11 services are paid for by Medicare for a beneficiary, the payment would increase to $175 per service.
The number of cardiac rehab program sessions would be limited to a maximum of two one-hour sessions per day for up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period of time if approved by the Medicare administrative contractor. Intensive cardiac rehab program sessions would be limited to 72 one-hour sessions, up to six sessions per day, over a period of up to 18 weeks.
The proposed rule also describes new pathways for physicians who participate in bundled payment models to qualify for financial rewards through the proposed Quality Payment Program. The bundled payment models in this proposed rule could qualify as Advanced Alternative Payment Models (APMs) beginning in 2018 and would include eligible clinicians who collaborate with participating hospitals.