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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.

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: Public Use Files for ACOs Posted with 2016 Performance Results

Oct. 27, 2017 – CMS released 2016 performance results for the Medicare Shared Savings Program ACOs, which accompany results for the Next Generation ACO model (first year) and the Pioneer ACO model (fifth and final year) released on October 13, 2017.  Links to download the PUFs for these ACO models are below. For analysis of the performance results, see the Kaiser Family foundation Evidence Link, an interactive resource that synthesizes the most up-to-date evidence on savings and quality for new payment and delivery system reform models in Medicare.

Medicare Shared Savings Program 2016 Results

Next Generation ACO Model 2016 Results (Performance Year 1)

Pioneer ACO Model 2016 Results (Performance Year 5)

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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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