January 06, 2017

CMS Publishes Episode Payment Model Final Rule

The Centers for Medicare & Medicaid Services (CMS) has published its final rule outlining four new episode payment models (EPMs) — three focused on cardiac care and one focused on orthopedic care.

The rule, released on Dec. 20, 2016, also finalizes updates to the Comprehensive Care for Joint Replacement Model (CJR). These models will reward hospitals that work together with physicians and other providers to avoid complications, prevent hospital readmissions and speed recovery.

The four new models are:

  • The Acute Myocardial Infarction (AMI) Model
  • The Coronary Artery Bypass Graft (CABG) Model
  • The Cardiac Rehabilitation (CR) Incentive Payment Model
  • The Surgical Hip and Femur Fracture Treatment (SHFFT) Model

Acute care hospitals in selected geographic areas will participate in retrospective episode-based payments for items and services related to AMI, CABG, and SHFFT treatment and recovery, beginning with a hospitalization and extending for 90 days following hospital discharge.

According to the rule, the four new payment models and the updated CJR model give clinicians additional opportunities to qualify for a 5 percent incentive payment through the Advanced Alternative Payment Model (APM) path under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Quality Payment Program (QPP).

In addition, the final rule describes the Medicare ACO Track 1+ Model, a new accountable care organization (ACO) opportunity designed for small practices. It incorporates more limited downside risk than is currently present in the Medicare Shared Savings Program (MSSP) Tracks 2 or 3, but with elements of Track 3 including prospective beneficiary assignment. The new ACO Track 1+ model, which begins in 2018, is also approved as an Advanced APM under the QPP.

Learn more about the new EPMs, updated CJR and the Medicare ACO Track 1+ in this fact sheet and on the CMS Innovation Center website.