June 12, 2025
Dr. Mehmet Oz
Administrator
Centers for Medicare & Medicaid Services
Department of Health & Human Services
200 Independence Ave, SW
Washington, DC 20201
Re: CMS-1833-P; Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2026 Rates; Quality Programs Requirements; and Other Policy Changes
Dear Administrator Oz,
On behalf of Accountable for Health, we appreciate the opportunity to provide feedback on concepts included in the Fiscal Year (FY) 2026 Hospital Inpatient Prospective Payment System (IPPS) proposed rule, specifically the Transforming Episode Accountability Model (TEAM) and the Request for Information (RFI) on the transition to Fast Healthcare Interoperability Resources (FHIR)-based digital quality measurement.
Accountable for Health is a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care. We aim to inform policy that advances the movement in the health care system toward accountable care that achieves better outcomes, improved care experiences, increased access and lower costs.
Episode-based payment reforms can be effective in driving targeted improvements on health care outcomes, experiences and cost when coupled with primary care-centered total cost of care models and other integrated specialty care strategies. Models like TEAM can create a structure that lends itself toward greater levels of accountable care, including more familiarity with data and responsibility for care management, experiences and outcomes across settings. We were pleased to see CMS build on the lessons learned from more than a decade of testing previous bundled payment models with the implementation of TEAM and urge CMS to use experience with other models to guide decision making on new policies under consideration.
Further, the success of accountable care models like TEAM relies on real-time data and technology platforms that produce actionable insights to drive quality improvement and cost savings. We appreciate this Administration’s focus on quality measures that reflect better outcomes for patients. While the transition to digital quality measurement must be thoughtful, policies that expand the health system’s collective view of whole-person care outcomes are a necessary support for greater clinical and financial accountability for health and health care.
TEAM Feedback
Slated to launch on January 1, 2026, TEAM is a mandatory, episode-based alternative payment model in which selected acute care hospitals would coordinate care for people who undergo a surgical procedure included in the model and assume responsibility for quality and cost of care from the surgery through 30 days after the beneficiary leaves the hospital. The proposed rule includes a number of policies that CMS is considering, but not proposing, as it prepares to launch the model. We appreciate CMS’ transparency on potential new policies that could be implemented after the model begins. We reiterate our strong belief that model policies should be aligned where appropriate and that mid-model changes should be minimized to the extent possible.
Replacing the Area Deprivation Index (ADI) with the Community Deprivation Index (CDI)
CMS proposes to rename the social needs risk adjustment factor to the beneficiary economic risk adjustment factor and replace the use of the area deprivation index (ADI) in the construction of the beneficiary economic risk adjustment variable, with a similar but slightly modified census block group deprivation index, the Community Deprivation Index (CDI). This would be the same construction methodology as the ACO REACH model.
Accountable for Health supports this policy change and believes that the CDI will more accurately assess beneficiary risk factors. This is an improvement over the social needs risk adjustment factor, as the ADI has been shown to mask disparities in certain areas and the policy brings TEAM in alignment with ACO REACH. More broadly, A4H encourages CMS to continue to prioritize ACO expansion to economically underserved areas. Our members stand ready to work with CMS on additional interventions and investment in infrastructure to support health care delivery in rural and underserved regions.
Low Volume Hospitals
CMS proposes to maintain the current policy of having no low volume episode policy, given that Track 1 of the model has no downside risk and CMS expects most TEAM participants to elect Track 1 for the first performance year. However, CMS seeks comments on several policy approaches that could be adopted in the future to address prior commenters’ concerns about low volume providers participating in TEAM.
These policies include establishing a low volume threshold, such as applying a low volume threshold to specific episode categories in the baseline period for a given performance year with the threshold either aligned to either episode threshold used in BPCI-A or something different, and/or limiting the scope of potential low volume policy to safety net and rural hospitals. Considered policies also include guardrails to protect low volume hospitals from losses, such as not holding TEAM participants accountable for episode categories where the low volume threshold is not met in a specific performance year, or subjecting low volume providers to a lower level of financial risk and gain for episode categories.
A4H supports incorporation of a low volume threshold into TEAM. A4H encourages CMS to align the low-volume threshold with the threshold used for BPCI Advanced, which was 41 episodes during the four-year baseline period for a given episode. Anything lower than a 41-episode threshold would be too low to offer sufficient protection from catastrophic losses.
Referral to Primary Care Services
CMS currently requires a TEAM participant to refer a TEAM beneficiary to a supplier of primary care services on or prior to discharge from an anchor hospital or anchor procedure. CMS does not propose to change this existing requirement but seeks comment on several policy refinements that could be adopted through future rulemaking.
CMS notes that its current policy allows the TEAM participant to refer the TEAM beneficiary to a supplier of primary care services that is different from the supplier of primary care services that the TEAM beneficiary has an established relationship with. CMS is considering, but not proposing, several refinements to this policy, reflecting a concern that the current policy could disrupt established care relationships, limit access to high-value care, and disrupt fair competition in provider markets.
To address these concerns, CMS is considering various approaches for requiring TEAM participants to determine whether the TEAM beneficiary has an established primary care relationship within the two previous years before episode initiation and if so, to require the TEAM participant to refer the beneficiary to its established provider. CMS is also considering removing the referral requirement entirely or limiting it only to TEAM beneficiaries without evidence of an established primary care relationship in the prior two years. CMS is concerned that policies requiring the TEAM participant to identify an established care relationship would be too administratively burdensome and could not be completed prior to the TEAM beneficiary’s discharge from the hospital or hospital outpatient department.
A4H supports maintaining a primary care referral requirement in TEAM. However, we do not believe CMS should mandate hospitals refer patients specifically to a primary care provider that they have visited in the past two years as shown in claims. This increases participant burden since claims are not integrated with EHR. Further, if patients have moved or deliberately changed their primary care provider, this could prevent connecting the patient to a more appropriate source of care. More broadly, we urge CMS to ensure this policy does not overburden providers with paperwork and adheres to patient preferences.
We also support additional incentives to connect patients to a longitudinal primary care relationship and believe that CMS should adopt additional safeguards to ensure that patients who are already aligned to a provider be “tucked back in” to that provider. For example, CMS could consider including care coordination warm hand off CPT II codes like the Advanced Care Planning (ACP) code included as a BPCI Advanced ACP quality measure. In the case of a provider in an ACO, TEAM can create an opportunity for collaboration between the hospital and the ACO to improve care transitions and ensure longitudinal care strategies.
In response to CMS’ concerns regarding the administrative burden associated with identifying established care relationships, we offer the following comment. First, hospitals are currently required as a Medicare Condition of Participation (CoP) to make a reasonable effort to send an admission, discharge or transfer event notification to a patient’s established primary care practitioner or primary care practice group or entity. The burden associated with identifying established care relationships for purposes of a TEAM referral should be relatively low since hospitals are already required to make a reasonable effort to identify these relationships today. Second, in the FY 2025 IPPS proposed rule, CMS solicited comment on TEAM model overlap issues, including ways to implement a notification process for shared savings or total cost of care participants to alert them that one of their aligned beneficiaries has initiated an episode in TEAM. Such a notification process could be used as a referral channel for established care relationships.
Limited Deferment Period
CMS proposes that any new hospital, as identified by Medicare ID (CMS Certification Number—CCN) with an initial effective date after December 31, 2024, would not be required to participate in TEAM immediately and would have at least one full performance year of participation deferment before being required to participate in the model. CMS also proposes that any hospital that begins to satisfy the definition of TEAM participant after December 31, 2024, would not be required to participate in TEAM immediately and would have at least one full performance year of participation deferment before being required to participate in the model.
CMS considered allowing new hospitals to participate with no downside risk for the first performance year, but stated that requiring the hospitals to participate in the first full performance year, even with no downside financial risk, would not provide sufficient opportunity for them to prepare for the participation requirements.
A4H supports the one-year deferment period for new hospitals but urges CMS to allow these hospitals to participate in track 1 with no downside risk. This is crucial for participants to measure and refine processes, like all other mandatory participants who have the option to do so in their first performance year.
Digital Quality Measurement RFI
CMS solicits comment on its anticipated approach to the use of HL7 Fast Healthcare Interoperability Resources (FHIR) in electronic clinical quality measure (eCQM) reporting, noting its aim to transition over time to a fully digital quality measurement (dQM) landscape that promotes interoperability and increase the value of reporting quality measure data. CMS poses questions on a number of topics including eCQM FHIR conversion activities; data standardization for quality measurement and reporting; the timeline under consideration for FHIR-based eCQM reporting; and measure development and reporting tools.
Accountable for Health’s comments on this RFI are focused on the Medicare Promoting Interoperability Program given the application of these requirements to hospital and health system accountable care participants. Accountable care entities are generally comprised of many participant providers, each of whom has one or more electronic medical records (EMRs) and numerous other digital tools that collect and store information on a patient’s health and health care. To report eCQMs, quality information must be extracted, standardized and aggregated across participants by the accountable care entity. Accurate quality reporting – both of eCQMs now and dQMs in the future – rely on EMRs to function as expected. Real-world testing requirements should be preserved to ensure that EMRs do in fact function as expected in native technology environments, and new technologies such as Bulk FHIR and API infrastructure should further be preserved and expanded to enable reporting on larger populations such as those aligned to accountable care entities.
Specific responses to the questions posed in the RFI are below.
- eCQM FHIR Conversion Activities: CMS notes that an important initial step in its dQM strategy is to ensure current eCQMs are specified using the FHIR standard and to allow these measures to be calculated consistently using standardized data represented in FHIR. Bulk FHIR is critical for quality reporting on a large population such as those aligned to an accountable care entity. Moving forward, it will be important for CMS to specify in FHIR all available elements in USCDI 4-QI-Core and USCDI Core. CMS should also consider allowing reporting throughout the entire year as part of the transition process. Supplementary activities such as executive tracked training and Connectathons will encourage engagement in FHIR testing activities.
- Data Standardization for Quality Measurement and Reporting: We are not aware of any deficiencies or gaps in the DEQM IG that must be addressed before it can be used for reporting to CMS on eCQMs using FHIR APIs. Baseline policies that must be maintained or adopted prior to reporting on eCQMs using FHIR APIs include real-world testing for EMRs and Bulk FHIR standards. Providers, including accountable care entities, will also need a mechanism for managing the security of API.
- Timeline Under Consideration for FHIR-Based cCQM Reporting: Twenty-four months does not offer enough time for implementation of FHIR-based eCQM reporting. One of our members recently implemented FHIR-based eCQM reporting over a five-year period, and reports that vendors are likely to be able to complete this on a three year – 36 month – timeline with additional guidance and experience. One challenge for CMS to consider is that smaller, independent providers do not have the resources to do this on their own or to hire a vendor. As such, we recommend that CMS consider an implementation timeline and policies flexible enough to accommodate a range of provider types at different resource levels. This should include an option for manual reporting, including manual aggregation of provider-level data.
- General Solicitation of Comments: CMS requested comment on whether the Trusted Exchange Framework and Common Agreement (TEFCA) could support exchange of FHIR-based quality measures. While we believe that TEFCA is an important exchange mechanism, our members suggest that a barrier to using TEFCA to support this use case is the existing primary source verification reporting requirement for HEDIS reporting.
Conclusion
Accountable for Health appreciates the opportunity to provide comments on the proposed rule. If you have any questions about our comments or need more information, please do not hesitate to contact Mara McDermott, mmcdermott@accountableforhealth.org.
Sincerely,
Mara McDermott
CEO
Accountable for Health
June 12, 2025
Dr. Mehmet Oz
Administrator
Centers for Medicare & Medicaid Services
Department of Health & Human Services
200 Independence Ave, SW
Washington, DC 20201
Re: CMS-1833-P; Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2026 Rates; Quality Programs Requirements; and Other Policy Changes
Dear Administrator Oz,
On behalf of Accountable for Health, we appreciate the opportunity to provide feedback on concepts included in the Fiscal Year (FY) 2026 Hospital Inpatient Prospective Payment System (IPPS) proposed rule, specifically the Transforming Episode Accountability Model (TEAM) and the Request for Information (RFI) on the transition to Fast Healthcare Interoperability Resources (FHIR)-based digital quality measurement.
Accountable for Health is a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care. We aim to inform policy that advances the movement in the health care system toward accountable care that achieves better outcomes, improved care experiences, increased access and lower costs.
Episode-based payment reforms can be effective in driving targeted improvements on health care outcomes, experiences and cost when coupled with primary care-centered total cost of care models and other integrated specialty care strategies. Models like TEAM can create a structure that lends itself toward greater levels of accountable care, including more familiarity with data and responsibility for care management, experiences and outcomes across settings. We were pleased to see CMS build on the lessons learned from more than a decade of testing previous bundled payment models with the implementation of TEAM and urge CMS to use experience with other models to guide decision making on new policies under consideration.
Further, the success of accountable care models like TEAM relies on real-time data and technology platforms that produce actionable insights to drive quality improvement and cost savings. We appreciate this Administration’s focus on quality measures that reflect better outcomes for patients. While the transition to digital quality measurement must be thoughtful, policies that expand the health system’s collective view of whole-person care outcomes are a necessary support for greater clinical and financial accountability for health and health care.
TEAM Feedback
Slated to launch on January 1, 2026, TEAM is a mandatory, episode-based alternative payment model in which selected acute care hospitals would coordinate care for people who undergo a surgical procedure included in the model and assume responsibility for quality and cost of care from the surgery through 30 days after the beneficiary leaves the hospital. The proposed rule includes a number of policies that CMS is considering, but not proposing, as it prepares to launch the model. We appreciate CMS’ transparency on potential new policies that could be implemented after the model begins. We reiterate our strong belief that model policies should be aligned where appropriate and that mid-model changes should be minimized to the extent possible.
Replacing the Area Deprivation Index (ADI) with the Community Deprivation Index (CDI)
CMS proposes to rename the social needs risk adjustment factor to the beneficiary economic risk adjustment factor and replace the use of the area deprivation index (ADI) in the construction of the beneficiary economic risk adjustment variable, with a similar but slightly modified census block group deprivation index, the Community Deprivation Index (CDI). This would be the same construction methodology as the ACO REACH model.
Accountable for Health supports this policy change and believes that the CDI will more accurately assess beneficiary risk factors. This is an improvement over the social needs risk adjustment factor, as the ADI has been shown to mask disparities in certain areas and the policy brings TEAM in alignment with ACO REACH. More broadly, A4H encourages CMS to continue to prioritize ACO expansion to economically underserved areas. Our members stand ready to work with CMS on additional interventions and investment in infrastructure to support health care delivery in rural and underserved regions.
Low Volume Hospitals
CMS proposes to maintain the current policy of having no low volume episode policy, given that Track 1 of the model has no downside risk and CMS expects most TEAM participants to elect Track 1 for the first performance year. However, CMS seeks comments on several policy approaches that could be adopted in the future to address prior commenters’ concerns about low volume providers participating in TEAM.
These policies include establishing a low volume threshold, such as applying a low volume threshold to specific episode categories in the baseline period for a given performance year with the threshold either aligned to either episode threshold used in BPCI-A or something different, and/or limiting the scope of potential low volume policy to safety net and rural hospitals. Considered policies also include guardrails to protect low volume hospitals from losses, such as not holding TEAM participants accountable for episode categories where the low volume threshold is not met in a specific performance year, or subjecting low volume providers to a lower level of financial risk and gain for episode categories.
A4H supports incorporation of a low volume threshold into TEAM. A4H encourages CMS to align the low-volume threshold with the threshold used for BPCI Advanced, which was 41 episodes during the four-year baseline period for a given episode. Anything lower than a 41-episode threshold would be too low to offer sufficient protection from catastrophic losses.
Referral to Primary Care Services
CMS currently requires a TEAM participant to refer a TEAM beneficiary to a supplier of primary care services on or prior to discharge from an anchor hospital or anchor procedure. CMS does not propose to change this existing requirement but seeks comment on several policy refinements that could be adopted through future rulemaking.
CMS notes that its current policy allows the TEAM participant to refer the TEAM beneficiary to a supplier of primary care services that is different from the supplier of primary care services that the TEAM beneficiary has an established relationship with. CMS is considering, but not proposing, several refinements to this policy, reflecting a concern that the current policy could disrupt established care relationships, limit access to high-value care, and disrupt fair competition in provider markets.
To address these concerns, CMS is considering various approaches for requiring TEAM participants to determine whether the TEAM beneficiary has an established primary care relationship within the two previous years before episode initiation and if so, to require the TEAM participant to refer the beneficiary to its established provider. CMS is also considering removing the referral requirement entirely or limiting it only to TEAM beneficiaries without evidence of an established primary care relationship in the prior two years. CMS is concerned that policies requiring the TEAM participant to identify an established care relationship would be too administratively burdensome and could not be completed prior to the TEAM beneficiary’s discharge from the hospital or hospital outpatient department.
A4H supports maintaining a primary care referral requirement in TEAM. However, we do not believe CMS should mandate hospitals refer patients specifically to a primary care provider that they have visited in the past two years as shown in claims. This increases participant burden since claims are not integrated with EHR. Further, if patients have moved or deliberately changed their primary care provider, this could prevent connecting the patient to a more appropriate source of care. More broadly, we urge CMS to ensure this policy does not overburden providers with paperwork and adheres to patient preferences.
We also support additional incentives to connect patients to a longitudinal primary care relationship and believe that CMS should adopt additional safeguards to ensure that patients who are already aligned to a provider be “tucked back in” to that provider. For example, CMS could consider including care coordination warm hand off CPT II codes like the Advanced Care Planning (ACP) code included as a BPCI Advanced ACP quality measure. In the case of a provider in an ACO, TEAM can create an opportunity for collaboration between the hospital and the ACO to improve care transitions and ensure longitudinal care strategies.
In response to CMS’ concerns regarding the administrative burden associated with identifying established care relationships, we offer the following comment. First, hospitals are currently required as a Medicare Condition of Participation (CoP) to make a reasonable effort to send an admission, discharge or transfer event notification to a patient’s established primary care practitioner or primary care practice group or entity. The burden associated with identifying established care relationships for purposes of a TEAM referral should be relatively low since hospitals are already required to make a reasonable effort to identify these relationships today. Second, in the FY 2025 IPPS proposed rule, CMS solicited comment on TEAM model overlap issues, including ways to implement a notification process for shared savings or total cost of care participants to alert them that one of their aligned beneficiaries has initiated an episode in TEAM. Such a notification process could be used as a referral channel for established care relationships.
Limited Deferment Period
CMS proposes that any new hospital, as identified by Medicare ID (CMS Certification Number—CCN) with an initial effective date after December 31, 2024, would not be required to participate in TEAM immediately and would have at least one full performance year of participation deferment before being required to participate in the model. CMS also proposes that any hospital that begins to satisfy the definition of TEAM participant after December 31, 2024, would not be required to participate in TEAM immediately and would have at least one full performance year of participation deferment before being required to participate in the model.
CMS considered allowing new hospitals to participate with no downside risk for the first performance year, but stated that requiring the hospitals to participate in the first full performance year, even with no downside financial risk, would not provide sufficient opportunity for them to prepare for the participation requirements.
A4H supports the one-year deferment period for new hospitals but urges CMS to allow these hospitals to participate in track 1 with no downside risk. This is crucial for participants to measure and refine processes, like all other mandatory participants who have the option to do so in their first performance year.
Digital Quality Measurement RFI
CMS solicits comment on its anticipated approach to the use of HL7 Fast Healthcare Interoperability Resources (FHIR) in electronic clinical quality measure (eCQM) reporting, noting its aim to transition over time to a fully digital quality measurement (dQM) landscape that promotes interoperability and increase the value of reporting quality measure data. CMS poses questions on a number of topics including eCQM FHIR conversion activities; data standardization for quality measurement and reporting; the timeline under consideration for FHIR-based eCQM reporting; and measure development and reporting tools.
Accountable for Health’s comments on this RFI are focused on the Medicare Promoting Interoperability Program given the application of these requirements to hospital and health system accountable care participants. Accountable care entities are generally comprised of many participant providers, each of whom has one or more electronic medical records (EMRs) and numerous other digital tools that collect and store information on a patient’s health and health care. To report eCQMs, quality information must be extracted, standardized and aggregated across participants by the accountable care entity. Accurate quality reporting – both of eCQMs now and dQMs in the future – rely on EMRs to function as expected. Real-world testing requirements should be preserved to ensure that EMRs do in fact function as expected in native technology environments, and new technologies such as Bulk FHIR and API infrastructure should further be preserved and expanded to enable reporting on larger populations such as those aligned to accountable care entities.
Specific responses to the questions posed in the RFI are below.
Conclusion
Accountable for Health appreciates the opportunity to provide comments on the proposed rule. If you have any questions about our comments or need more information, please do not hesitate to contact Mara McDermott, mmcdermott@accountableforhealth.org.
Sincerely,
Mara McDermott
CEO
Accountable for Health
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