Advanced APM option may be to join a consolidated risk-bearing
ACO with significant downside risk.
On December 20, 2016, CMS released the Advancing Care Coordination through Episode Payment Models (EPMs) final rule. 5 The
rule establishes three new Medicare EPMs for acute myocardial
infarction (AMI), coronary artery bypass graft (CABG), and surgical hip/femur fracture treatment (SHFFT) procedures provided in
designated geographic areas. The rule also includes provisions to
finalize the Cardiac Rehabilitation (CR) Incentive Payment program
and to integrate bundled payment programs into the QPP.
Under the final rule, acute care hospitals that are reimbursed
under the Inpatient Prospective Payment System and are located
in 98 metropolitan statistical areas (MSAs) selected by CMS will be
required to participate in retrospective EPMs for Medicare fee-for-service beneficiaries receiving care during AMI and CABG episodes.
The agency will implement the SHFFT model in 67 MSAs where
the Comprehensive Care for Joint Replacement program is already
in place. An AMI, CABG, or SHFFT model episode will begin with
an inpatient admission and end 90 days after discharge. The episode
of care will include the inpatient stay and related care covered under
Medicare Parts A and B, including hospital care, post-acute care, and
physician services, within 90 days of discharge. CMS will continue
to pay participating hospitals, providers, and suppliers according to
the current Medicare fee-for-service rates.
The AMI EPM, the CABG EPM, and the CR Incentive Payment
program will be tested for five performance years—July 1, 2017,
through December 31, 2021. CMS estimates that 1,120 acute care
hospitals will participate in the AMI and CABG models, and 860
hospitals will participate in the SHFFT model. CMS has indicated
that these bundled payment models should qualify for the Advanced
APM track of MACRA, thereby providing exclusion from MIPS. 6
The federal government will continue to support a payment
system that encourages changing physician payment from fee for
service to payment that is based on transparent performance metrics,
patient experience, and patient outcomes. There is an early opportunity for significant financial reward from a high-value program that
is focused on quality metrics, HCAHPS scores, care coordination,
and the post-acute disposition. The next hurdle will be maximizing reimbursement through an optimized patient-focused APM. ♦
The author is grateful to the bundled care team members at Baystate Medical Center for their assistance.
1. Mechanic RE. When new Medicare
payment systems collide. N Engl J Med.
2. Clough JD, McClellan M. Implementing
MACRA: Implications for physicians
and for physician leadership. JAMA.
3. Shahian DM, He X, O’Brien SM, et al.
Development of a clinical registry-based
30-day readmission measure for coronary
artery bypass grafting surgery. Circulation.
4. Meeker D, Linder JA, Fox CR, et al.
Effect of behavioral interventions on
inappropriate antibiotic prescribing among
primary care practices: A randomized
clinical trial. JAMA. 2016; 315( 6):562-570.
5. Centers for Medicare & Medicaid Services.
Episode payment models: General
information. Available at: innovation.cms.
gov/initiatives/epm. Accessed January 24,
6. Centers for Medicare & Medicaid Services.
Notice of proposed rulemaking for
bundled payment models for high-quality,
coordinated cardiac and hip fracture care.
Available at: www.cms.gov/Newsroom/
Accessed January 24, 2017.