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The Evidence Link: Latest Announcements in Medicare Payment and Delivery System Reform

Keep current with Medicare Payment and Delivery System Reform news, including recently-proposed rules, newly-released spending and quality results, and announcements on model changes.


CMS: Proposes New Home Health Fraud Identification Demonstration

May 29, 2018 – CMS announced a new demonstration to test alternative procedures for identifying and reducing fraudulent Medicare billing by home health agencies. Providers would have the option to either submit to a 100% pre-claim review or 100% post-payment review to demonstrate compliance with Medicare regulations. CMS contractors would review provider claims until they reach specified approval rates, after which providers may be relieved from claim reviews, except for spot checks. Providers who choose not to submit to the 100% pre/post reviews would receive a 25% payment reduction on all home health service claims. CMS has proposed initially testing the demonstration in five states (Florida, Illinois, Ohio, North Carolina, and Texas), with options to expand to other states. The public comment period lasts 60 days. This demonstration is not being conducted through CMMI.

Federal Register Notice (PDF)

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CMS/CMMI: Releases Final Independent Evaluation on Comprehensive Primary Care (CPC) Initiative

May 23, 2018 – Mathematica Policy Research completed its fourth and final evaluation of the CPC Initiative—a medical home model launched by CMMI, which tested whether aligning care management fees, quality goals, and efficiency incentives across payers (including Medicare) ultimately decreases spending and increases quality of care. The evaluation found that the four-year CPC initiative achieved no net Medicare savings relative to comparison groups. Although gross Medicare expenditures for CPC practices increased 1% less than comparison practice spending over the four years of the initiative (not statistically significant), care management fees exceeded these savings. Hospitalizations and emergency department visits significantly decreased for CPC beneficiaries relative to comparison groups, but few or no differences were found across other quality measures, including patient satisfaction, relative to comparison groups. In the final year, the median participating practice received approximately $180,000 in care management fees.

MPR Evaluation Report

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GAO: Releases Report on Innovation Center Status and Performance

Apr. 25, 2018 – GAO released a report on the status and performance of the Center for Medicare and Medicaid Innovation (CMMI). The report found that through FY2016, CMMI obligated $5.6 billion of the $10 billion that the ACA appropriated through 2019. CMMI has implemented a total of 37 payment and delivery system reform models across Medicare, Medicaid, and CHIP, through March 2018, with varying results on spending and quality. GAO notes that CMMI has used independent evaluation results to inform future models, as well as expand current models (e.g., Pioneer ACO model and Diabetes Prevention Program). GAO also reported that CMMI assessed itself as having met or partially met its three main performance targets: reducing the growth in health care spending while promoting better quality of care; identifying and testing new models; and accelerating the spread of successful models.

GAO Report Text (PDF)

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CMS/CMMI: Issues RFI for New Provider Contracting Model

Apr. 23, 2018 – CMS announced that it is seeking input to inform the development of direct provider contracting (DPC) between payers and primary care or multi-specialty group practices within traditional Medicare, Medicare Advantage, and Medicaid. According to the RFI, broad options for these models could include fixed monthly per-beneficiary payments to practices, two-sided financial risk, greater practice flexibility, and reduced claims submission requirements.  The RFI asks for feedback on many specific questions regarding DPC model design, performance measurement, and coordination with other alternative payment models, such as ACOs. Comments are due May 25, 2018.

RFI Text (PDF)

Press Release

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CMS/CMMI: Releases Comments from 2017 “New Direction” RFI

Apr. 23, 2018 – CMS posted public comments submitted in response to its September 2017 Request for Information (RFI), which sought input and feedback from stakeholders on the future direction of CMMI. Comments focused on eight focus areas outlined in the RFI: “(1) Increased participation in Advanced Alternative Payment Models (APM); (2) Consumer-Directed Care & Market-Based Innovation Models; (3) Physician Specialty Models; (4) Prescription Drug Models; (5) Medicare Advantage (MA) Innovation Models; (6) State-Based and Local Innovation, including Medicaid-focused Models; (7) Mental and Behavioral Health Models; and (8) Program Integrity.” CMS received over 1,000 submitted responses, and stated that this input will contribute to future model development and design.

Press Release

Public Comments

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CMS/CMMI: Announces New Innovation Center Director

Apr. 6, 2018 – HHS Secretary Alex Azar announced the appointment of Adam Boehler as Deputy Administrator and Director of the Center for Medicare and Medicaid Innovation, beginning April 9, 2018. Boehler is the former CEO and founder of Landmark Health, a home health care company. Previously, he was the chairman and founder of Avalon Healthcare Solutions.

HHS Announcement

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CMS/CMMI: Releases Independent Report on Maryland All-Payer Model Results

Mar. 30, 2018 – RTI International released its third annual report on the Maryland All-Payer Model, which tests whether an all-payer hospital payment system (e.g., the Maryland system) leads to higher quality care and lower costs for Medicare, Medicaid, and commercial payers. The report states that total per beneficiary Medicare spending, as well as inpatient admissions for Medicare beneficiaries, decreased in Maryland hospitals throughout the first three years of the demonstration, relative to a comparison group. Results were mixed on rates of emergency department visits for avoidable conditions, and unplanned readmissions and emergency visits 30 days post-discharge were similar to the comparison group. Patient experience scores were also lower for beneficiaries in Maryland hospitals than in comparison hospitals.

RTI International: Third Annual Report

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GAO: Releases Report on Results of Medicaid Demonstrations

Feb. 20, 2018 – A GAO report on state-led and federal Medicaid demonstration evaluations examined the quality of several past and ongoing demonstrations, the process by which evaluations are completed, and how the evaluations have influenced Medicaid policy. The study recommended that 1) demonstration evaluations should be made public in a more timely manner, therefore allowing for policymakers to consult evaluations during current policy decision-making processes; 2) CMS should issue, in writing, a requirement that states complete a final evaluation for each demonstration; and 3) CMS should issue a set of criteria for when states may complete “limited evaluation” for certain demonstrations.

GAO Report

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CMS/CMMI: Releases Independent Report for Phase Two of Nursing Home Demonstration

Feb. 16, 2018 – RTI International released its first annual report on the second phase of the Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents. While the first phase (2013–2016) focused on clinical and educational interventions, the second, current phase focuses on testing financial incentives via a payment model that pays clinicians to provide health care to nursing facility residents on-site rather than in a hospital setting. This first report for phase two was focused on matching appropriate comparison groups to intervention groups, which was successfully completed for each state. An analysis, including results, of phase two performance will be released in the next report.

RTI International: First Annual Report

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Bipartisan Budget Act of 2018 Includes ACO Provisions and Extends Independence at Home Model

Feb. 9, 2018 – The Bipartisan Budget Act of 2018 included several provisions affecting Medicare payments to ACOs, including 1) expanding telehealth coverage for Medicare beneficiaries in ACOs with two-sided risk; 2) allowing ACOs to pay Medicare patients directly (up to $20 per primary care service) in ACOs with two-sided risk; and 3) directing CMS to establish procedures for voluntary alignment for ACOs, which allows Medicare beneficiaries to select an ACO by identifying their primary care clinicians—a direction that CMS had already initiated. Additionally, the Budget Act extended the Independence at Home demonstration, which focuses on home-based team care for frail seniors, two additional years.

Bipartisan Budget Act of 2018 Text

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CMS/CMMI: Cancels second “Decisions Support” Model Initiated in 2016

Feb. 2, 2018 – CMS/CMMI canceled the Direct Decision Support Model, which was designed to test whether clinical decision support activities provided by organizations outside clinical offices would have a positive effect on beneficiary engagement and empowerment, as well as utilization and cost of care. This model had similar goals to the within-clinical setting Shared Decision Making Model, which focused on ACOs and was canceled November 13, 2017. Although CMS initiated the designs for both models in 2016, the agency did not make either active. CMS cited operational challenges and lack of ACO interest as reasons for the cancellations.

Direct Decision Support (DDS) Model

Shared Decision Making (SDM) Model

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CMS/CMMI: Releases Systematic Review of CMMI Primary Care Initiatives

Feb. 2, 2018 – A meta-analysis of six CMMI primary care initiatives examined questions regarding 1) the impact of the models on costs, hospital admissions, emergency department visits, and readmissions; 2) external and internal factors affecting the results; 3) evaluation challenges; and 4) needs for further testing. Overall, the results found that most of these initiatives reduced spending growth in Medicare before accounting for care management fees, with mixed and modest quality gains. Medical practices were at various levels of readiness for practice transformation and evaluators experienced data and methodological challenges in addition to the need for more time to assess impact of changes on Medicare spending and quality.

Systematic Review of CMMI Primary Care Initiatives Final Report

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CMS/CMMI Announces “BPCI Advanced” – the Newest Bundled Payment Model

 Jan. 9, 2018 – CMS unveiled the next iteration of the Bundled Payment for Care Improvement model (BPCI). The new model, set to begin October 1, 2018, will be called “BPCI Advanced.” Like its predecessor, provider participation in this model is voluntary. Participants may choose from 32 clinical episodes, 29 of which are a subset of the original BPCI and include inpatient hospitalizations, and 3 of which are new, outpatient episodes. CMS states that it expects BPCI Advanced to meet the qualifications required by law to be an Advanced Alternative Payment Model (APM), thus making participating providers eligible for an automatic increase in their Medicare fee-schedule payments starting in 2020. Applications are due March 12, 2018.

CMS/CMMI Summary Description of BPCI Advanced

Detailed Description and Application for BPCI Advanced

8 FAQs: Medicare Bundled Payment Models

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CMS: More ACOs Join the Medicare Shared Savings Program in 2018

Jan. 5, 2018 – CMS posted new public use files that provide the names and types of ACOs now participating in the Medicare Shared Savings Program (MSSP). The total number of ACOs for the 2018 performance year increased to 581, up from 480 in 2017. With this increase, ACOs now account for 10.5 million Medicare beneficiaries in traditional Medicare, compared to 9.5 million in 2017.

CMS Performance Year 2018 MSSPs

8 FAQs: Medicare ACO Models

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CMS: Final Rule Cancels and Changes Mandatory Bundled Payment Models

Nov. 30, 2017 – CMS released a final rule that cancels several mandatory bundled payment models that were scheduled to start in 2018 and reduces the number of areas with mandatory participation in a current hip/knee replacement model. Specifically, CMS is canceling the “Episode Payment Models” group, which included the Surgical Hip and Femur Fracture Treatment (SHFFT) model, the Coronary Artery Bypass Graft (CABG) model, and the Acute Myocardial Infarction (AMI) model. CMS also canceled the Cardiac Rehabilitation (CR) Incentive Payment model. Each of these models was designed to be mandatory for hospitals in designated geographic areas. For 2018, CMS is reducing the number of mandatory geographic areas from 67 to 34. In addition, CMS will make participation voluntary for low-volume and rural hospitals in the remaining mandatory geographic areas. CMS proposed these changes through the rule-making process on August 17, 2017. CMS also included an interim final rule for the Comprehensive Care for Joint Replacement (CJR) model regarding significant hardship of participating hospitals located in areas that experience extreme and uncontrollable circumstances, such as major hurricanes.

CMS Final Rule Full Text

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CMS: Proposed Rule for the Medicare Diabetes Prevention Program (MDPP) Expanded Model (2018)

Nov. 2, 2017 – CMS finalized a set of implementation policies for the MDPP expanded model starting in 2018. The MDPP stems from an earlier Diabetes Prevention Program (DPP) model, which partnered with the YMCA. The DPP model met the statutory criteria for expansion because it achieved Medicare savings of $2,650 for each person enrolled in the model, covered the cost of the program, and improved patient outcomes. Like the DPP, the MDPP focuses on preventing progression of type 2 diabetes in individuals with clinical indication of pre-diabetes and includes a specified “core curriculum” with follow up contact. Participating suppliers are eligible for performance-based payments based on beneficiary weight loss and session attendance. Suppliers will also be able to provide in-kind incentives to beneficiaries to increase patient engagement in healthy behavior change.

CMS Proposed Rule Full Text

CMS Office of the Actuary: Certification Memo for DPP

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CMS/CMMI: Innovation Center New Direction Announced: Request for Information (RFI) Seeking Comments on Future Direction

Sep. 20, 2017 – CMS announced that it is seeking stakeholder input and feedback on the future direction of CMMI through an informal Request for Information (RFI). This RFI provides a list of Guiding Principles and introduces eight focus areas for potential models: (1) Increased participation in Advanced Alternative Payment Models (APM); (2) Consumer-Directed Care & Market-Based Innovation Models; (3) Physician Specialty Models; (4) Prescription Drug Models; (5) Medicare Advantage (MA) Innovation Models; (6) State-Based and Local Innovation, including Medicaid-focused Models; (7) Mental and Behavioral Health Models; and (8) Program Integrity. CMS states that comments will be received through November 20, 2017.

“New Direction” Request for Information (RFI) Full Text

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