National associations representing patient care organizations are responding to the RFI (request for information) from the federal Centers for Medicare and Medicaid Services (CMS).
In its RFI, CMS on July 18 provided the following by way of background:
“In 2021, the Innovation Center announced a strategic refresh with a vision of having a health care system that achieves equitable outcomes through high quality, affordable, person-centered care. To guide this updated vision, the Innovation Center intends to design, implement, and evaluate future episode-based payment models with a focus on five strategic objectives, including advancing health equity and driving accountable care. With a bold goal of having 100 percent of Medicare fee-for-service (FFS) beneficiaries and the vast majority of Medicaid beneficiaries in an accountable care relationship by 2030, we acknowledge that additional opportunities for accountable care relationships with specialists are needed.”
Further, CMS stated, “One approach to support accountable care and to create an avenue for specialists to participate in value-based care initiatives is through episode-based payment models. The Innovation Center has launched several episode-based payment models (also known as bundled-payment models), four of which are either ongoing or being implemented in 2023. These models help to address the inefficiencies in traditional Medicare FFS, where providers are paid for each item or service, which may drive volume over value and fragment care. By bundling items and services into an episode of care, providers are better incentivized to coordinate patient care and to avoid duplicative or unnecessary services. Early episode-based payment demonstrations were narrow in scope and assessed particular design aspects, such as the use of gainsharing mechanisms or bundled payments for inpatient stays.”
Later on in that section, CMS officials noted that “The Innovation Center is utilizing lessons learned from our experience with the Bundled Payments for Care Improvement (BPCI), Bundled Payments for Care Improvement Advanced (BPCI Advanced), and the Comprehensive Care for Joint Replacement (CJR) models to design and implement a new episode-based payment model focused on accountability for quality and cost, health equity, and specialty integration. To further inform development of the potential new model, we are soliciting input from those with additional insight and frontline experience with bundled payments. This request for information (RFI) is not seeking feedback on models which address particular conditions over a longer period of time, such as the Enhancing Oncology Model and the Kidney Care Choices Model. Specifically, we are requesting input on a broader set of questions related to care delivery and incentive structure alignment and six foundational components: Clinical Episodes; Participants; Health Equity; Quality Measures, Interoperability, and Multi-Payer Alignment; Payment Methodology and Structure; and Model Overlap.” And officials noted that the agency is hoping to “improve care transitions for the beneficiary; and increase engagement of specialists within value-based, accountable care.”
Prior to the deadline for response on August 17, leaders at the Charlotte-based Premier Inc. health alliance and the Chicago- and Washington, D.C.-based American Hospital Association (AHA) responded, with both associations provided detailed input for CMS officials.
Premier leaders offered detailed critique, posted to the alliance’s website. They began by stating that “Premier submitted comments to CMS’ request for information (RFI) on the design of a future episode-based payment model. CMS will use responses to the RFI to inform potential future rulemaking or other policy developments on a new bundled payment model that is centered around improving beneficiary care, lowering Medicare expenditures, reducing fragmentation and increasing care coordination across healthcare settings.”
And they made the following points, urging CMS officials to do the following:
• Focus episodic models on acute conditions or procedures that have defined and well-established care practices or medical protocols.
• Design episodes that are tailored to the specific condition or procedure and needs of the patient, including varying the length of the episode, defining the initial episode trigger and refining what items or services are included in the episode based on clinical protocols.
• Ensure a mandatory episodic model provides meaningful opportunities for participants to take on two-sided risk, including opportunities for upside financial gain and gradual risk options. CMS must also ensure to establish appropriate provider exclusion criteria and provide sufficient information in advance of the model start.
• Grant precedence to providers participating in existing alternative payment models (APMs) when addressing overlap with a new mandatory episodic model. CMS should also provide opportunities for voluntary participation under the new mandatory model.
• Maintain flexibility and establish incentives to support accountable care organizations (ACOs) and episode initiators in developing partnerships that improve care coordination and patient outcomes.
• Adopt new incentives and modify existing policies to support the integration of specialists into ACOs, including supporting ACOs in the development of “shadow bundles.”
• Modify existing episodic target price methodologies to adopt regional or national target pricing, provide greater transparency around trend factors, improve risk adjustments to account for high-cost patients and modify timing of financial reconciliations.
• Advance health equity by improving the collection and standardization of social determinations of health (SDOH) data and by adjusting episodic payment methodologies to ensure target prices appropriately account for the needs of underserved patients.
• Ensure quality measures are relevant to the care provided in the episode and minimize burden for participants.
The AHA, meanwhile, posted a very long response, sent to CMS under the signature of Ashley Thompson, the association’s senior vice president for policy. Below are a few excerpts of the response, which can be read in full on the AHA’s website:
“The AHA applauds the Centers for Medicare & Medicaid Services’ (CMS’) continued efforts to reform reimbursement and develop innovative payment models to incentivize efficiency and improved outcomes. Our members support the U.S. health care system moving toward the provision of more accountable, coordinated care and are continuing to redesign delivery systems to increase value and better serve patients. We believe that episode-based payment models could help further these efforts to transform care delivery through financial accountability and improved care coordination.”
The AHA’s leaders noted that their member organizations have participated in a variety of bundled payment models over the past 13 years, “including Bundled Payments for Care Improvement (BPCI), BPCI Advanced (BPCI-A), and Comprehensive Care for Joint Replacement (CJR). Model design elements like participation criteria, clinical episodes, payment methodologies, metrics and incentives have changed over the course of time.” Per that, they urged CMS officials to consider several “core principles”:
They are as follows:
Transparency. Models’ methodology, data and design elements should be transparently shared with all potential participants. Proposed changes should be vetted with stakeholders.
Flexible Model Design. Bundled payment model design should be flexible, incorporating features such as voluntary participation, the ability to choose individual clinical episodes, the ability to add components/waivers and options for participants to leave the model(s).
Risk Adjustment. Models should include adequate risk adjustment methodologies and account for social needs. This will ensure they do not inappropriately penalize participants treating the sickest, most complicated and underserved patients. The risk adjustment methodologies should be updated as necessary through the model in coordination with participants and the broader stakeholder community.
Resources to Support Initial Investment. Upfront investment incentives should be provided to support organizations in their transition to episode-based payment. For example, to be successful in such models, hospitals, health systems and provider groups must invest in additional staffing and infrastructure to support care delivery redesign and outcomes tracking. This includes hiring additional staff (like community health workers, care coordinators and analysts) as well as investing in information technology (IT) (software to track outcomes, electronic health record (EHR) interfaces, etc.).
Waivers to Address Barriers to Clinical Integration and Care Coordination. Models should waive the applicable fraud and abuse laws that inhibit care coordination to enable participating hospitals to form the financial relationships necessary to succeed. They should also provide maximum flexibility to identify and place beneficiaries in the clinical setting that best serves their short- and long-term recovery goals. This entails waiving Medicare program regulations that frequently inhibit care coordination and work against participants’ efforts to ensure that care is provided in the right place at the right time
Appropriate On Ramp. Model participants should have an adequate on ramp or glidepath to transition to episode-based payment models. They must have adequate time to implement care delivery changes (integrating new staff, changing clinical workflows, implementing new analytics tools, etc.) and review data prior to initiating the program.
Balancing Risk Versus Reward. Models should also balance the risk versus reward in a way that encourages providers to take on additional risk but does not penalize those that need additional time and experience before they are able to do so. A glidepath approach should be implemented, gradually migrating from upside only to downside risk.
Establishing Guardrails to Ensure Hospitals Aren’t Competing Against Their Own Best Performance. Models should provide guardrails to ensure that participants do not have to compete against their own best performance and have incentives to remain in models for the long-term.
Adequate Model Duration. Models should be long enough in duration to truly support care delivery transformation and assess impact on outcomes. Episode-based models will take time to demonstrate impact on outcomes. Historically, many have been too short and/or have had multiple, significant design changes even within the designated duration, making it difficult for participants to self-evaluate and change course when necessary.
Timely Availability of Data. Model participants should have readily available, timely access to data about their patient populations. We would encourage dedication of resources from CMS (staff and technology) to provide program participants with more complete data as close to real-time as possible.
