The Centers for Medicare & Medicaid Services (CMS) will be holding a stakeholder meeting on Monday, August 15, 2016, at 1:00 p.m. CT. The topic will be regarding the newly released proposed rule updating the Programs of All-Inclusive Care for the Elderly (PACE). CMS has summarized the proposed rule as follows.

This proposed rule would revise and update the requirements for the Programs of All-Inclusive Care for the Elderly (PACE) under the Medicare and Medicaid programs. The proposed rule addresses application and waiver procedures, sanctions, enforcement actions and termination, administrative requirements, PACE services, participant rights, quality assessment and performance improvement, participant enrollment and disenrollment, payment, federal and state monitoring, data collection, record maintenance, and reporting. The proposed changes would provide greater operational flexibility, remove redundancies and outdated information, and codify existing practice.

The proposed rule can be accessed at: https://www.federalregister.gov/public-inspection

The call in number is: 1-800-267-1577
Meeting number is: 999 551 883#

Authored By Brian Ellsworth, Director, Payment Transformation, Health Dimensions Group

In case you thought that election year politics would bring a slowdown in value-based transformation by the Medicare program, think again. On Monday, July 25, 2016, the Centers for Medicare and Medicaid Services (CMS) announced proposals for two new mandatory bundles for cardiac episodes (heart attacks and bypass surgery), a new cardiac rehabilitation incentive payment model, and an expansion of the recently implemented mandatory Comprehensive Care for Joint Replacement (CJR) model by adding hip and femur fractures to the already included lower joint replacement bundles. Episodic payment is here to stay!

These proposals will take effect July 1, 2017, if finalized as proposed. It is important to note that the mandatory joint replacement model went from proposal to implementation in just nine months. CMS is accepting comments on its proposal for 60 days, ending September 24, 2016.

Perhaps most interesting of all of these developments is that CMS indicates that another round of voluntary bundling under the Bundled Payments for Care Improvement (BPCI) program will be scheduled to start in CY 2018. The size and scope of this opportunity is unclear, but many providers were kicking themselves for not participating in the last round of voluntary bundling initiated in 2014.

Proposed Cardiac Bundles

Many of the key payment features of the newly proposed cardiac bundles are based off the joint replacement model, including:

• Hospitals as the required risk-bearing entity;
• Mandatory markets (98 regions in the proposed rule);
• 90-day episodes starting from the end of the hospitalization;
• Explicit linkage of shared savings amounts to attainment of quality metrics;
• Use of waivers of certain payment rules; and,
• Ability of other providers to share in gains achieved by making an episode of care more efficient.

The target pricing methodology, incorporating phase-in to regional prices and assumption of greater risk over time, is also similar in structure to CJR. Thus, it is clear that many of the payment features enacted in the joint replacement model are paving the way for expansion of episodic payment.

Proposed Cardiac Rehabilitation Payment Model

The proposal includes a new payment model for cardiac rehabilitation. Under this new approach, incentive payments over and above normal payments would be made to hospitals to promote the provision of cardiac rehabilitation for heart attack and bypass surgery cases. This incentive structure would be tested in 45 markets outside of the 98 proposed mandatory regions, as well as within 45 of the mandatory markets.

Proposed CJR Expansion

Also of note is the proposal to expand CJR to include hip and femur surgeries, which has been a popular diagnostic category under the existing voluntary bundled payments program (over a quarter of hospital-initiated bundlers and one-third of post-acute–initiated bundlers have elected this category). This proposed expansion gives hospitals even greater incentives to redesign orthopedic surgeries and the subsequent post-acute care.

Physician Payment Incentives

A new aspect of these proposals is the articulation of how these models will fit into the physician value-based payment incentives proposed in this year’s physician payment rule. CMS is proposing a pathway in these mandatory bundles that will permit them to qualify as advanced alternative payment models (APMs) under the physician payment rule, meaning that participating doctors will qualify for additional payments over and above any shared savings obtained through these new payment models—giving physicians a stake in ensuring their rapid adoption. The opportunity to qualify as participating in advanced APMs is part of CMS’ efforts to drive payment models that explicitly link payment and quality and to encourage active participation by doctors in risk sharing.

What Does This All Mean?

CMS clearly intends to meet its goals of 50 percent of fee-for-service payments in alternative payment methods by 2018. This, combined with the growth of Medicare Advantage and accountable care organizations, means that most Medicare payments will be subject to value-based payment incentives within two years. Episodic payment is here to stay and will increase in size and scope as new mandatory and voluntary payment models are rolled out. At-risk entities will be tuned into the cost and quality of the entire episode of care, including preventing readmissions and managing post-acute care.

Providers that are nimble and understand how to create value (lower costs at higher quality) will be positioned for success, while others that cannot move the needle will be left out as networks are narrowed and performance expectations increase. It is not too early to position your organization to succeed in this brave new world. For additional information please contact Brian Ellsworth, MA, Director of Payment Transformation at 860-874-6169 or bellsworth@hdgi1.com

Authored by Erin Shvetzoff Hennessey, Vice President, Business Solutions

Who

Congress passed the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act), a bipartisan bill, on September 18, 2014, and it was signed into law on October 6, 2014. The bill was sponsored by Rep. Dave Camp [R-MI-4] and was co- sponsored by Rep. Sander Levin [D-MI-9], Rep. Kevin Brady [R-TX-8], Rep. Jim McDermott [D-WA-7], Rep. Earl Blumenauer [D-OR-3], Rep. Don Kind [D-WI-3], Rep. Patrick Tiberi [R-OH-12], Rep. Diane Black [R-TN-6], and Rep. Linda Sanchez [D-CA-38].

The House Ways and Means and Senate Finance Committees stated, “The IMPACT Act is the core building block needed for future Medicare PAC reforms, leading to more accountable, quality-driven services.”

What

The IMPACT Act requires the submission of standardized data by post-acute care (PAC) settings, including skilled nursing facilities (SNFs), home health agencies (HHAs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs). The statute requires: development of uniform quality and resource measures; a core set of assessment items across settings; and, detailed timelines and objectives. These requirements provide data uniformity, improved care and outcomes, the ability to compare quality and data across care settings, improved acute care discharge planning, and the sharing of data to improve care coordination. Assessment items include:

• Skin integrity and changes in skin integrity;
• Functional status, cognitive function, and changes in function and cognitive function;
• Medication reconciliation;
• Incidence of major falls;
• Transfer of health information and care preferences when an individual transitions;
• Resource use measures, including total estimated Medicare spending per beneficiary;
• Discharge to community; and,
• All-condition risk-adjusted potentially preventable hospital readmissions rates.

Where

Over 5.5 million Medicare enrollees are served in PAC settings and over 42 percent of Medicare fee-for-service beneficiaries are discharged from acute care to PAC:

• SNF—15,600 facilities, average length of stay (ALOS) of 39 days, Medicare spending of $287 billion
• HHA—12,311 agencies, Medicare spending of $18 billion
• IRF—1,166 facilities, ALOS of 13 days, Medicare spending of $6.7 billion
• LTCH—420 facilities, ALOS of 26 days, $5.5 billion

When

Implementation of the IMPACT Act comprises five parts:

1. Incorporation of standardized assessment into existing assessment tools across PAC providers.
2. Development and public reporting of quality measures across settings.
3. Hospitals and post-acute care providers required to provide quality measures to consumers when transitioning to a PAC provider; not doing so results in 2 percent penalty.
4. Government is required to conduct studies and provide reports to link payment to quality.
5. Centers for Medicare and Medicaid Services (CMS) receives $11 million in funding to use payroll data to measure staffing in SNF setting.

Key implementation milestones include:

• October 2016: standardized resource use measure; some quality reporting begins.
• October 2017: confidential feedback provided on previous year’s reports.
• October 2018: standardized assessment data required; public quality data available; penalties go into effect.
• October 2021: CMS and MedPAC to report on prospective payment; study on hospital assessment data.

Why

The escalating cost of post-acute care, combined with lack of uniform data and reporting across post-acute care, has created a focus on reduction of post-acute care spending. The goals of the IMPACT Act are to improve clinical outcomes and reduce Medicare expenses through an interoperable core data site, site-neutral payment policies, value-based payment approaches, and improved care transition and discharge planning.