August 17, 2023
Centers for Medicare & Medicaid Services
Department of Health & Human Services
200 Independence Ave, SW
Washington, DC 20201
Center for Medicare & Medicaid Innovation
Center for Medicare & Medicaid Services
2810 Lord Baltimore Drive
Windsor Mill, MD 21244
Re: Request for Information: Episode-Based Payment Model [CMS-5540-NC]
Dear Administrator Brooks-LaSure,
On behalf of Accountable for Health, we appreciate the opportunity to provide feedback on the request for information (RFI) on the design of a future episode-based payment model. Accountable for Health is a non-partisan, national advocacy and policy organization accelerating the adoption of effective accountable care. We aim to support policymakers to advance the movement in the health care system toward accountable care that achieves better outcomes, improved care experiences, increased access and lower costs.
The Centers for Medicare & Medicaid Services (CMS) set a goal of enabling all Medicare beneficiaries and the vast majority of Medicaid beneficiaries to participate in accountable care relationships by 2030.1 This goal builds on similar goals of previous Administrations to improve health outcomes and lower costs by advancing effective accountable care. Effective accountable care improves health outcomes, expands access, enhances care coordination and controls costs. In short, it better meets the health needs of people and populations as compared to an often fragmented fee-for-service reimbursement system.
Primary care-centered total cost of care models, such as accountable care organizations (ACOs), have served as the backbone of accountable care delivery system reform efforts to date.2 Recent episode-based payment reforms have focused on acute events (e.g., heart attacks) and major procedures (e.g., joint replacements), representing a small component of the impact specialists have on health care outcomes, experiences and costs.3 Models have made progress toward creating a more holistic approach to payment and health care delivery, but more can be done to create an integrated specialty care strategy that aligns toward whole person care. While an episode-based payment model requiring participation from certain entities can be one part of the agency’s episode-based payment strategy, A4H believes that immediately deploying a longitudinal approach that integrates specialty care models with total cost of care models will best serve people, providers, and the Administration’s goals.
Episode-Based Payment Models Improve Care, Lower Costs
As discussed in the RFI, the Innovation Center has substantial experience with episode-based payment models, including the Comprehensive Care for Joint Replacement (CJR) model, Bundled Payments for Care Improvement (BPCI) and Bundled Payments for Care Improvement Advanced (BPCI-A). In general, in these models, providers continue to receive standard fee-for-service payments for services furnished during the episode of care. Payments are then compared to a target price that CMS sets. Participants may receive additional payments if the cost of the episode is less than the target price and quality thresholds are achieved. The predetermined target prices bundle items and services furnished to the beneficiary across care settings. Bundled payment models may include either upside-only or two-sided risk arrangements.
Experience with episode-based payment models demonstrates that these models can improve care coordination, expand access to services including those that address social need, and lower costs. Episode-based accountability 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. CMS’s evaluations show that providers undertook efforts such as developing discharge plans, engaging patients in care plans, following-up with patients, tracking patient outcomes post-discharge, and communicating with post acute care providers about patient care.4
Our members shared examples of episode-based payment models driving implementation of medication reconciliation strategies at each point of a patient’s care journey. In episodic models, care teams ensure that prescribed medications do not result in duplication, omission, or incorrect dosages. Care teams review medications the patient took prior to the episode that must be stopped due to changes in health condition or new prescriptions. The review with the patient and his or her care partners how and why to take each medication. And care teams help ensure patients have access to prescribed medications, including reviewing how to take a medication, who will pick up the patient’s medication, and identifying and recommending lower cost medications, where possible. Medication reconciliation is one example of how episode-based models create accountability for the patient outside of the single site of care, such as the hospital, where he or she receives care, coordinating across post-acute sites.
In addition, our members shared examples of how episode-based accountability has created incentives and processes for addressing social needs. Meals were one example – connecting patients post discharge to organizations that can provide meal services to help individuals regain their strength and maintain their independence at home. Patients with food insecurity that are offered a choice of stay in a skilled nursing facility (SNF) or home health may elect the SNF because in that setting that they have access to meals, even if the home would be an appropriate and safe location for their care. When there is an accountable model in place, resources such as Meals on Wheels can be identified and deployed to close gaps, like providing meals, enabling patients to return home. This has significant implications for patient satisfaction and outcomes, and for the cost of that care. The difference between a 30-day home health stay and a 30-day SNF stay is substantial, around $16,000 to $18,000. When a program is in place to create accountability for the episode of care, participants in the program, like discharge planners, social workers and care navigators can ensure and facilitate the right care in the right place at the right time, helping patients return home sooner and creating solutions that meet people’s health care needs.
Experience with episode-based models also shows potential for cost savings. The CMS Innovation Center released a synthesis of results across bundled payment models and concluded that BPCI reduced episode costs for the majority of clinical episodes evaluated (50 out of 67) where 27 were statistically significant with an average decline of about $1,630 per clinical episode (6.1%). The results from the first two performance years of the CJR model indicated 3.7% reduction in gross Medicare payments of $997 per episode. These reductions were attributed to increases in efficiency as care is shifted from institutional post-acute care to less intensive post-acute services (home health and outpatient therapy).
BPCI-A was recently extended and is currently slated to run through 2025. The CJR model runs through the end of 2024. CMS has indicated a mandatory episode-based payment model would begin no sooner than 2026. The Innovation Center should ensure that there is continuity across the portfolio so that providers progress along the accountable care glidepath.
Comprehensive Specialty Care Strategy
To achieve the goals of having all Medicare and most Medicaid beneficiaries in accountable care relationships by 2030, CMS should develop and deploy a longitudinal specialty care strategy that integrates with total cost of care models in the short term. There are several ways that the agency can leverage its experience and existing models to more quickly create voluntary options for meaningful specialist engagement and integration in accountable care.
The agency can create opportunities for specialists within its existing total cost of care portfolio. As the largest of the total cost of care delivery models, the Medicare Shared Savings Program (MSSP) can be a powerful mechanism to engage specialists in total cost of care delivery. The CMS Innovation Center can support this collaboration by providing additional tools to facilitate nested episode-based payment models within MSSP. This could include additional data sharing about specialist performance; supports and tools for understanding and leveraging data; development of contract templates or voluntary models that could be integrated within the MSSP structure at the ACO’s election. In partnership with MSSP ACOs, specialty care models could be implemented voluntarily with the option to negotiate shared responsibilities for population health outcomes and costs and the opportunity to share in savings. These partnerships have strong potential to benefit the Medicare program and the people Medicare serves. As an example, one MSSP ACO that incorporated a nested specialty program for beneficiaries with kidney disease saw a 33 percent reduction in emergency department visits and a 20 percent reduction in total cost of care among this specialized population.
Another way to encourage this collaboration is through ACO contracting that allows greater flexibility to move away from fee-for-service reimbursement. Innovation Center ACO models like ACO Realizing Equity Access and Community Health (REACH) create cash flow mechanisms that enable ACOs to pursue contracts with specialists that test payments that move away from fee-for-service reimbursements. Providers may also be able to leverage or share experiences from Medicare Advantage, where payments are not strictly fee-for-service in nature. The Innovation Center should engage in a dialogue with REACH participants and subcapitated MA providers to better understand best practices and opportunities to continue to support subcontracting from ACOs that moves away from fee-for-service reimbursement toward more sustainable specialty care payment including accountability for health outcomes.
CMS can also continue to layer incentives for specialty care coordination in its models similar to the integration component of Making Care Primary (MCP). In MCP, CMS will provide data to participants regarding specialists in their region, prioritizing specific measures related to cardiology, pulmonology and orthopedics. Eligible specialty care partners who have an arrangement with an MCP participant will also receive additional per-month payments for taking on care delivery requirements. Experimentation with care management or care coordination payments may serve as a more powerful incentive for specialty care alignment and could be layered into other models in the CMS Innovation Center portfolio as a way to increase participation and begin to form the infrastructure for broader based future collaborations.
CMS should ensure that there are strong and compelling programs for specialists to participate in total cost of care models. As an example, CMMI’s Comprehensive Kidney Care Contracting (CKCC) model is a voluntary total cost of care model that is specific to the nephrology specialty. CKCC is designed specifically for nephrologists and Medicare beneficiaries with kidney disease, and the specialized nature of the model has already led to a significant uptake in participation – data suggests that over 50% of independent nephrologists in the U.S. are currently participating in the CKCC model. CMS should continue programs and expand access to models such as CKCC that encourage specialists to actively participate in total cost of care accountability, particularly focusing on specialists that care for patients with highly specialized, complex, and chronic needs.
In addition, CMS should ensure there are strong incentives for specialists to participate in accountable care. Specifically, the Medicare Access and CHIP Authorization Act (MACRA) included incentives for participation in advanced alternative payment models (APMs), including total cost of care models that have two-sided risk. To qualify for the incentive payment, APM entities must meet certain thresholds of patients or revenue “through” the APM. MACRA’s intent was to encourage expansion of APM participation. However, because of the way that threshold is calculated (currently at the APM entity level) specialists, who often see many patients not attributed to the ACO, diluted the ACO entity’s performance against the MACRA thresholds. As a result, many ACOs removed specialists so the entity could hit the threshold – the exact opposite of MACRA’s intent. The threshold calculation should be revisited altogether to ensure it is meeting its stated goals of expanding participation in APMs.
In the most recent Medicare Physician Fee Schedule proposed rule, CMS proposes calculating MACRA bonus thresholds at the individual clinician level. This is notable given that BPCI-A and other previous episode model tests qualify as A-APM, which means that the model participants may qualify for this bonus, if they meet the thresholds. It may be more challenging to meet these thresholds as individual participants and we are concerned that this approach will not create the strong and clear incentive needed to drive participation in accountable care. It may not be clear to clinicians whether they would qualify as individuals, particularly in the early years. Strong, clear incentives for participation in alternative payment models are necessary to ensure robust adoption of ACOs, deployment of innovative contracting strategies, and growth in participation in nested bundles or other specialty care models. CMS should ensure that the threshold calculations are transparent, clear and directionally strong toward incenting participation in accountable care delivery models. We encourage the agency to consider performing these calculations at both the individual and entity level so that all participating providers who are eligible receive their incentives.
Finally, we note that MACRA’s incentives shift for the 2024 performance year/2026 payment year. The 3.5 percent bonus for participating in an advanced APM is currently set to expire. A 0.5 percent favorable differential to the conversion factor for qualifying participants is set to begin. The conversion factor increase may have complicated implications for APM participants if that increase counts against financial performance (if it is an expenditure that counts against them when compared to the benchmark). CMS can ensure that it provides clear information to clinicians about their options and potential incentives for participating, and that these incentives clearly align in favor of accountable care.
Required Participation in Episode-Based Models
After sufficient voluntary model options have been created and providers have had an opportunity to elect participation, assuming there are providers who have not elected to participate in total cost of care or episode-based models, CMS should pursue a limited mandatory model test. CMS and the Innovation Center should work closely with stakeholders including providers, payers and consumer organizations to ensure that this model is properly designed, including selecting the appropriate conditions and episodes of care, setting and creating stability for the target price, and ensuring that the model is prioritizing people’s health care needs. A targeted, specific mandatory model may provide opportunities to engage providers on the glidepath to risk who have not yet engaged, create meaningful learnings for the future of delivery system transformation, and have the potential to be expanded if it is successful. Clinicians and entities participating in voluntary total cost of care models in a meaningful way should be exempt from mandatory models. Creating such an exemption is another powerful incentive for voluntary participation in total cost of care models.
Finally, CMS should strive wherever possible to create multi-payer alignment in episode-based models, total cost of care models with nested specialty components, and specialty care models. Our members experience vast differences across payers today, creating additional burden, complexity, and disincentives for participation in accountable care. Fostering alignment across payers will encourage greater participation. CMS can facilitate cross-payer collaboration by sharing additional model details so that payers can replicate modeling, make data easier to access, and make information about cost and quality performance transparent and accessible.
Accountable for Health appreciates the opportunity to respond to the RFI. If you have any questions about our comments or need more information, please do not hesitate to contact Mara McDermott, email@example.com.
Accountable for Health