On April 22, 2019, the Centers for Medicare and Medicaid Services (CMS) announced two new voluntary risk-sharing payment models—Professional Population-Based Payment (PBP) and Global PBP. Under the Professional PBP model, CMS will pay participating organizations (referred to as Direct Contracting Entities or DCEs) a monthly, risk-adjusted primary care capitation payment, as well as 50 percent of shared savings/losses for enhanced primary care services. The Global PBP model, which is aimed at larger organizations, offers a higher level of risk and reward. DCEs participating in the Global PBP will receive/be responsible for 100 percent of shared savings/losses and will have two capitation payment options. The first option is the same primary care capitation payment as in the Professional PBP model, and the second option is a total care capitation payment for all services provided by the DCE and preferred providers with whom the DCE has an agreement. Under either model, DCEs may offer patients certain “benefit enhancements” for the purpose of promoting accessibility to innovative and affordable care.
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Fee-for-service
CMS Final Rule on Episode Payment Models and Revisions to CJR Model
By Robinson+Cole's Health Law Group on
In December, the Centers for Medicare & Medicaid Services (CMS) issued a final rule (Final Rule) implementing new and revised episode payment models (EPMs) developed by the CMS Innovation Center. The Final Rule continues CMS’ transition of Medicare payment methodologies away from fee-for-service and towards value-based payments, including by incentivizing care coordination efforts and tying payments to quality improvement.
New EPMs: The Final Rule implements three new EPMs for episodes of care surrounding (i) acute myocardial infarction (AMI); (ii) coronary artery bypass graft (CABG); and (iii) surgical hip/femur fracture treatment excluding lower extremity joint replacement (SHFFT). Each episode of care encompasses a beneficiary’s inpatient stay as well as all related care within 90 days after discharge covered under Medicare Parts A and B. The initial performance year for the EPMs will start July 1 and expire December 31, 2017, and be followed by four successive performance years (2018-2021). Participation in the AMI and CABG EPMs will mandatory for acute care hospitals located in 98 randomly-selected metropolitan statistical areas (MSAs), and participation in the SHFFT EPM will be mandatory for hospitals in the 67 MSAs that currently participate in CMS’s comprehensive care for joint replacement model (CJR Model). The EPMs are designed to incorporate downside risk starting in 2019, but allow participants to assume downside risk in 2018 in order to qualify for potential incentive payments under the Medicare Access and CHIP Reauthorization Act (MACRA), by participating in an Advanced Alternative Payment Model.
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