CMS Makes Big Changes to Three Payment Models
August 18, 2017 03:20 PM
The Centers for Medicare & Medicaid Services (CMS) announced on Tuesday, August 15, a proposed rule that would discard two bundled payment models and reduce the number of providers required to participate in a third, while also cutting the number of mandatory geographic areas participating in the Comprehensive Care for Joint Replacement (CJR). In justifying the move, the CMS noted requests from providers to participate more in the design of the payment models.
The number of mandatory geographic areas participating in the CJR model would drop by almost half, from 67 to 34, and the CMS also proposed to exclude low-volume hospitals – those with fewer than 20 joint replacements over three years – in the remaining mandatory areas beginning in February 2018. Providers could continue to participate in the model if they choose to do so and rural hospitals in the remaining mandatory markets could also choose to participate.
The proposed rule would cancel the Episode Payment Models and the Cardiac Rehabilitation incentive payment model, which were scheduled to begin on Jan. 1, 2018. These cardiac pay models were estimated to save Medicare $159 million over five years.
NAHC’s concern over these developments – which we have heard from our members -- is that hospitals have been trying to control costs by pressuring physicians to limit the amount of home health care. NAHC has heard that only four physical therapy visits are routinely being ordered, regardless of patient circumstances or needs. In addition, no nursing or home care aides are being ordered, despite the fact that patients are entitled to these services under the home health benefit and such services are typical after a lower extremity joint replacement. The result is a Low Utilization Payment Adjustment (LUPA) payment to home health agencies rather than a full episodic payment.
These premature discharges from home health care have a negative impact on agencies’ quality measures, since the patients are not allowed to receive enough service to attain the desired health goals. For example, patients can be discharged from home health services with pain issues and decreased mobility. Patients with similar clinical profiles, but not subject to the demonstration, would likely stay on service until pain and mobility issues are resolved.
"Stakeholders have asked for more input on the design of these models. These changes make this possible and give CMS maximum flexibility to test other episode-based models that will bring about innovation and provide better care for Medicare beneficiaries," CMS Administrator Seema Verma said in a statement.
The CMS estimates the new model will slash savings over the next three years from $294 million to $204 million, due, in large part, to so many hospitals exiting the model. About 800 acute-care hospitals would have participated under the program without this proposed rule, but CMS estimates that will drop to, at most, 470, including 60 to 80 hospitals participating voluntarily.
CMS is considering allowing hip and knee replacement surgeries to take place at ambulatory surgical centers.
Comments are due October 17, 2017.