The Centers for Medicare & Medicaid Services (CMS) released a final rule (the Final Rule) on December 20, 2016 which involves 3 latest mandatory episode-based payment programs for cardiac care, as well as the expansion of the Comprehensive Care for Joint Replacement Model (CJR). The models are executed by the CMS Innovation Center, under authority issued in the Affordable Care Act (ACA). CMS also developed a Medicare ACO Track 1+ Model in the Final Rule to incentivize more small practices to proceed to performance-based risk.
The Cardiac Care Model (episode-based payment model for cardiac care) will need mandatory participation by entire hospitals within ninety-eight randomly-selected metropolitan statistical places (MSAs) with a population of almost 50,000 and nearly 75 Acute Myocardial Infarction (AMI) eligible cases. The Cardiac Care Model starts on the day of July 1, 2017 and sustains through December 31, 2021. Retrospective episode-based payments will be received by the hospitals for treating heart attacks and bypass surgeries, and they’ll be financially accountable for all care from the date of the hospitalization for the procedure through the date ninety days following the hospital discharge. AMI episodes (MS-DRGs 280-282 or 246-251) and coronary artery bypass graft surgery episodes (CABG) (MS-DRGs 231-236) are involved in the Cardiac Care Model.
The Cardiac Rehabilitation Incentive Payment Model has been included in the Final Rule, which will be utilized across 45 geographic areas. CMS is testing either a payment incentive can increase the utilization of cardiac rehabilitative services under this model. Incentive payments will be received by hospitals from CMS based on the frequency of cardiac rehabilitation utilization.
Furthermore, the CJR model is expanded under the Final Rule to involve surgical hip and femur fracture treatments (MS-DRGs 480-482). The CJR model has a goal to test bundled payments and quality measurement for an episode of care related to hip and knee replacements.
A new "Medicare ACO Track 1+ Model," has also been declared by CMS which starts in the year of 2018. This will test a payment model which involves a more restricted downside risk than in Tracks 2 or 3 of the Medicare Shared Savings Program (MSSP). CMS expects this will motivate more progression to performance-based risk, particularly among small practices. This model will qualify as an Advanced Alternative Payment Model under the (Medicare Access and CHIP Reauthorization Act of 2015). The latest model involves the following elements from Track 3 of the MSSP: prospective beneficiary assignment, which permits ACOs to know in advance the sufferer population for which the ACO is accountable; choice of symmetrical thresholds from which to begin sharing in savings or losses; and the choice to elect the Skilled Nursing Facility 3-Day Rule Waiver, which gives higher flexibility to the ACO.
CMS sustains to shift Medicare payments from traditional fee-for-service to value-based payments with these new alternative payment models. The new payment models, involving the Cardiac Rehabilitation Incentive Payment Model, Cardiac Care Model, and the expanded CJR, all qualify as Advanced Alternative Payment Models under MACRA, and hence present opportunities for clinicians who collaborate with participant hospitals to qualify for a 5% incentive payment.