Last week, the Centers for Medicare and Medicaid Innovation (CMMI)
released a Request for Information seeking feedback to inform a potential new episode-based payment model. The RFI includes many broad, open-ended questions for response with the goal of improving care transitions and role of specialists in value-based care who typically engage on a time-limited basis or treat a targeted condition or disease.
Comments are due August 17, 2023.
This RFI is in keeping with
CMS’ 2021 strategy refresh and objective to transition all Medicare fee-for-service and the majority of Medicaid into an “accountable” relationship for cost and quality by 2030. In recent years, accountable care models (ACOs) focused on primary care have been the central premise of CMMI’s strategy, however, in this request CMS acknowledges the role that specialists play in achieving its 2030 goals. CMS notes that it has four bundled payment models that are ongoing or being implemented in 2023 and intends to take lessons learned to design and implement a new episode model. CMMI alludes to a mandatory model with a potential shorter duration (i.e. 30-days) and its intent to implement no sooner than 2026 to ensure adequate time for preparation.
CMS seeks comment on the following topics:
- Care delivery and incentive structure alignment: How episodes can be appropriately structured to support the integration of specialty and primary care.
- Examples:
- How can CMS support multi-payer alignment for providers and suppliers in episode-based and population-based models?
- For population-based entities currently engaging specialists in episodic care management, what are the key factors driving improvements in cost, quality, and outcomes?
- Clinical Episodes: Types and characteristics of episodes that CMS should consider as the basis for a model, including feedback on existing models.
- Examples:
- 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? Should CMS test new clinical episode categories?
- How many clinical episode categories or service line groupings should be tested?
- 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.
- Which clinical episodes are most appropriate for collaboration between episode-based model participants and ACOs?
- Should different participants be accountable for different clinical episodes?
- Participants: Types of providers that may be ideally suited for episode-based payments, including discussions of participants in prior bundled payment models.
- Examples:
- 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 continue using precedence rules to attribute clinical episodes to a single accountable entity or consider weighted attribution for multiple accountable entities?
- Health equity: A key priority for the Biden administration, CMS asks questions specific to how an episode-based model should be structured to address health equity, including risk adjustment.
- Examples:
- 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.)
- 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?
- 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?
- What metrics should be used or monitored to adjust payment to assure health disparities are not worsened as an unintended consequence?
- Quality Measures, Interoperability and Multi-payer Alignment: How to engage other government and private sector payers in the payment redesign described by the model, as CMS has done in initiatives like the Comprehensive Primary Care Initiative .
- Examples:
- Which quality measures, currently used in established models or quality reporting programs, would be most valuable for use across care settings?
- What quality measures are other payers using to drive improvements in clinical episodes?
- Payment methodology and structure:
- Examples:
- How should CMS balance the need for predictable, achievable target prices with the need to create a reasonable possibility of achieving net Medicare savings?
- 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?
- 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)?
- Model overlap – Asking the key question of the interface of episode-based models set on top of accountable care models like ACOs.
- Examples:
- 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?
AHCA/NCAL will be responding to this RFI and incorporating feedback from a time-limited, small workgroup currently being convened on a “nested” bundle concept, the Reimbursement committee, and the PHM Council. Members interested in offering feedback should contact Nisha Hammel at
nhammel@ahca.org.