Society Comments on CMS Episode Payment Model Proposed Rule

This week, AMDA – The Society for Post-Acute and Long-Term Care Medicine submitted comments to the Centers for Medicare & Medicaid Services (CMS) on their Proposed Rule for Medicare entitled Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR). A brief summary of those comments are below:

Data Sharing: The Society agrees with CMS’ concerns about data sharing of key information for EPM collaborators. Practice groups in post-acute and long-term care (PALTC) medicine are often collaborators in these payment models and do not receive the information they need in order to assess their own performance and provide quality clinical care to patients in the episode. Thus, it is essential that CMS provide clear guidance on data transparency from the bundle initiators.

Episode Price-Setting Methodology (EPMs): The Society continues to be concerned that CMS does not have a proper risk adjustment methodology in place for patients’ transitions into the PALTC sector and strongly encouraged CMS to monitor implementation of these programs to ensure that it does not disincentivize clinicians from providing care for the most clinically complex and frequently the costliest patients, who are often cared for in the PALTC sector.

3-Day Hospital Stay Wavier: The Society reiterated its longstanding position on the elimination of the 3-day stay requirements and noted that CMS should have a wavier for all risk-bearing programs to provide the greatest flexibility for accountable care-based models to provide the necessary care at the appropriate setting with the appropriate level of care. The Society also noted their concerns about linking the 3-day wavier to the Five Star rating system. CMS is proposing to require that a SNF have three stars or greater on the Five Star system in order to waive the 3-day rule for SNF participants of new EPMs. The Society noted that the policy could have unintended negative consequences on beneficiary freedom of choice and access to care as well as asking CMS to provide flexibility and only use the measures within the Five Star program applicable to these bundles.

The Society recommended that CMS adopt an alternative approach to allowing SNFs and hospitals to use the 3-day rule wavier and that CMS modify the proposed criteria of “at least 3 start” to at least 3 starts overall OR at least 3 stars on both the staffing and quality measure components.

Advanced APM and CEHRT: The Society continued to comment about their concern that the requirement for use of Certified Electronic Health Record Technology (CEHRT) creates a much greater barrier for PALTC based practitioners than for those in acute and ambulatory settings and that there is still a significant gap of adoption and capability of these systems to effectively communicate with community-based physicians who treat patients in these facilities to meet the necessary criteria.

Selection of Proposed Quality Measures for the EPMs: The Society remains concerned that there are no required quality measures in any of the EMPS or in CJR that specifically address or reflect the quality of care physicians are delivering in PALTC and most of the required measures have a 30-day time horizon that will not cover much of that care.

Billing and Payment for Telehealth Services: The Society noted their support of the expansion of telehealth services in EPMs and agreed that CMS monitor the utilization of telehealth to ensure that patients get the face-to-face care that is necessary. However, the Society noted that “unless and until evidence of overutilization is obtained, we believe that an arbitrary limit could hinder access to appropriate care under the telehealth benefit, especially in underserved areas.”

Transfers and Gain Sharing Agreement: The Society noted that unless and until evidence of overutilization is obtained “we believe that an arbitrary limit could hinder access to appropriate care under the telehealth benefit, especially in underserved areas.” In addition, the Society would like to see an expanded role for PAC providers in the new EPMs rule. This includes incentives to build both technology and workforce capacity and a call for a BPCI Model-3-type arrangement within the proposed rule for three new EPMs where PAC providers can share in gains/risks of new EPMs. Currently, it is up to the hospitals to distribute the bundle and be in control of the gainsharing agreements.

The Society supports the use of gainsharing arrangements to allow providers to collaborate and benefit financially across provider sectors. However, the Society believes that gainsharing alone does not recognize the importance of PAC practices and partner facilities in the episodes of care.

To read the Societies full comments click here.