The Centers for Medicare
& Medicaid Services (CMS) has sent the Advancing Care Coordination through Episodic Payment Models
final rule to the Office of Management and Budget (OMB), which is the last step
before a final rule is published in the Federal Register.
The final rule would
implement a mandatory demonstration of two new cardiac episodic payment models
(EPMs) and one new orthopedic EPM in several locations nationally.
The two cardiac episodes—coronary
artery bypass graft (CABG) and acute myocardial infarction (AMI)—would be
tested in 98 markets. The specific markets will be listed in the final rule.
The surgical hip/femur fracture treatment (SHFFT) episode would be implemented
in the 67 markets currently testing the Comprehensive Care for Joint
Replacement (CJR) EPMs.
The new demonstrations are
scheduled to begin on July 1, 2017, and end on Dec. 31, 2021—an almost
The rule proposes 90-day
episodes, beginning with a hospital inpatient admission and ending 90 days
post-discharge. All Medicare Part A and B spending would be included in the
episode, including inpatient skilled nursing facility care, rehabilitation therapy,
and outpatient services.
The skilled nursing care profession
has expressed concerns about this rule.
“Inpatient hospitals in
the selected markets would be held at-risk for total spending, as well as for
outcomes in defined quality measures, across the 90-day episodes,” says Mike
Cheek, senior vice president for reimbursement policy and legal affairs at the
American Health Care Association (AHCA). “Hospitals will be able to establish gainsharing
relationships with other ‘collaborators,’ which include skilled nursing
facilities [SNFs] and outpatient therapy providers.”
Cheek notes that the
proposed rule also includes a waiver of the SNF three-day rule.
Cheek says that AHCA had
suspected that the Center for Medicare & Medicaid Innovation (CMMI) and CMS
would delay finalizing major proposed rules following the presidential election
to allow the next administration to make decisions about whether to finalize
Typically, the incoming president
directs agency and cabinet department heads to hold any rules that the agency
is preparing to finalize until a political appointee representing the new
president has reviewed and approved those regulations.
“AHCA will convey to the
incoming Congress and President-elect Trump’s transition team our deep concerns
about the rule and advocate for the rule to be delayed or revoked,” says Cheek.
“There are a variety of mechanisms the president can use, either on his own or
in conjunction with Congress, to overturn existing regulations or to stop the
promulgation of new regulations. We will be exploring all of these options.”