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 Provider Group Expresses Concerns About New CMS Payment Models


Providers are concerned about key aspects of a proposed rule that would implement three new Medicare episode payment models (EPM), establish a cardiac rehabilitation (CR) incentive payment model, and modify the comprehensive care for joint replacement (CJR) model.

Under the proposed rule, introduced by the Centers for Medicare & Medicaid Services (CMS) in August, acute care hospitals in certain selected geographic areas will participate in retrospective episode payment models targeting care for Medicare fee-for-service beneficiaries receiving services during acute myocardial infarction (AMI), coronary artery bypass graft (CABG), and surgical hip/femur fracture treatment (SHFFT) episodes.

 The new cardiac rehabilitation incentive payment model would test incentive payments to increase utilization of CR services for AMI and CABG patients, both alongside the AMI and CABG episode payment models, as well as in conjunction with traditional fee-for-service Medicare payments.

 These payment models would be implemented through rulemaking. The performance periods would begin on July 1, 2017, and continue through Dec. 31, 2021.

 In comments submitted to CMS this week, the American Health Care Association (AHCA) says that while it supports efforts to transition Medicare payments out of fee-for-service and into value-based care designs, it has “strong concerns that broad expansion of mandatory bundled payments may be negatively impacting patient outcomes and access to care.”

 AHCA says CMS should halt expansion of the proposed bundling initiatives until it has formally evaluated at least 12 months of data from the CJR demonstration, beginning with the start of downside risk-bearing on Jan. 1, 2017, and is able to demonstrate that these programs are not harmful to patients.

 AHCA would like to see an expanded role for post-acute care (PAC) providers in the new EPM rule, including guaranteed shared savings, as well as a commitment to more broadly test PAC-focused models of bundled payments. AHCA believes continued testing of PAC-only bundles should a critical piece of CMS’ shift to value-based payment design.

 “AHCA supports the use of gainsharing arrangements to allow providers to collaborate and benefit financially across provider sectors,” says Mike Cheek, senior vice president, reimbursement policy and legal affairs, for AHCA.

 In its comments, AHCA also urges CMS to modify the three-day skilled nursing facility (SNF) rule waiver that is currently tied to a skilled nursing care center’s rating under the Five-Star Quality Rating System. AHCA believes that instead CMS should waive the three-day stay based on SNF quality measures that are more directly applicable to post-acute care, particularly AMI, CAPB, or SHFFT care such as readmission, discharge to community, improved function, and patient satisfaction rates.

But barring that, AHCA wants CMS to either provide the three-day waiver for all SNFs or allow hospitals to refer patients to facilities with “at least three stars overall or at least three stars on both the staffing and quality measure components.” This approach would create the incentive to achieve higher staff levels and improved performance across Five Star’s 11 quality measures.

 In addition, AHCA has concerns about risk-adjustment methodology and how it could lead to hospitals gaming the system through patient steering and cherry picking.

 “AHCA firmly believes that without proper risk-adjustment methodology, bundled payment programs, such as CJR, create strong incentives for providers to avoid certain patients, particularly those who are predictably high-cost,” says Cheek. “Recent research has shown that in the absence of risk-adjustment, bundled payment initiatives may penalize providers that treat medically complex patients.”

 AHCA recommends that CMS consider adding measures to more aggressively monitor provider behaviors that would seek to restrict beneficiary access to care.

 “Despite PAC providers organizational commitment to bundled payments, hospitals may not adopt an inclusive approach and involve PACs to form effective partnerships to improve care, enhance the care experience, and reduce cost,” says Cheek.

 AHCA says it believes that the rule does not go far enough to address serious concerns about beneficiary choice, skimping on care, and conflict of interest—even though CMS proposes to monitor the new EPMs for beneficiary choice and notification, quality of care, delay of care, and access to care.

CMS will consider the comments it received from AHCA and other parties during the comment period before issuing the final rule.

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