/ en Sat, 14 Jun 2025 13:29:17 -0500 Wed, 07 May 25 11:11:54 -0500 <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Services (CMS) April 11 issued its hospital inpatient prospective payment system (PPS) and long-term care hospital (LTCH) PPS <a href="https://www.federalregister.gov/documents/2025/04/30/2025-06271/medicare-program-hospital-inpatient-prospective-payment-systems-for-acute-care-hospitals-and-the" target="_blank" title="Inpatient PPS and LTCH PPS proposed rules">proposed rule</a> for fiscal year (FY) 2026. The proposed rule included changes to the Transforming Episode Accountability Model (TEAM). Comments on the proposed rule are due to CMS by June 10. The final rule will be published on or around Aug. 1, with TEAM scheduled to begin on Jan. 1, 2026.</p><p>The proposed changes to TEAM address certain model design features that had not yet been finalized. Modifications also incorporate lessons learned from previous episode-based payment models like the Comprehensive Care for Joint Replacement (CJR) model and the Bundled Payments for Care Improvement Advanced (BPCI-A) model.</p><p>The AHA issued a separate advisory on the <a href="/advisory/2025-05-07-inpatient-pps-proposed-rule-fy-2026" target="_blank" title="AHA Inpatient PPS advisory">inpatient PPS</a> and will issue an LTCH PPS advisory soon. </p><div class="panel module-typeC"><div class="panel-heading"><p><strong>KEY HIGHLIGHTS</strong></p><p>CMS’ proposed changes to TEAM would:</p><ul><li>Allow certain new hospitals to defer or delay participation for one year.</li><li>Add one new quality measure — the Information Transfer Patient Reported Outcome-based Performance measure.</li><li>Apply a neutral quality measure score for TEAM participants with insufficient quality data.</li><li>Expand the Skilled Nursing Facility (SNF) 3-day Rule Waiver.</li><li>Not establish a low-volume policy but rather seek feedback on potential policy options.</li><li>Remove the voluntary health equity plan and the health-related social needs data policies.</li><li>Remove the voluntary decarbonization and resilience initiative.</li></ul></div></div><h2>AHA TAKE</h2><p>We appreciate that CMS continues to gather stakeholder feedback and make modifications to the TEAM. The AHA has long supported the adoption of value-based and alternative payment models to deliver high-quality care at lower costs; however, we are concerned that TEAM, even with the proposed changes, may force some hospitals to assume more risk than they can manage, threatening their ability to maintain access to quality care. Thus, we continue to urge the agency to make TEAM voluntary.</p><p>The need for this model to be voluntary is underscored by certain proposals in the rule, including not establishing a low-volume threshold. This approach would put at particular risk the many hospitals that are not of adequate size or in a position to support the investments necessary to succeed.</p><p>We look forward to continuing to work with CMS to update TEAM model design features.</p><h2>WHAT YOU CAN DO</h2><ul><li><strong>Determine</strong> if your organization is included in the model by reviewing the list of selected CBSAs and <a href="https://www.cms.gov/team-model-participant-list" target="_blank" title="List of selected hospitals">hospitals</a>.</li><li><strong>Share </strong>this advisory with your chief financial officer and other members of your senior management team, as well as key physician leaders and nurse managers, to examine potential changes for your hospital.</li><li><strong>Register</strong> to participate in AHA’s member-only <a href="https://aha-org.zoom.us/webinar/register/WN_Wc8sa6GRRoeAsoBwmloTyA#/registration" target="_blank" title="AHA Member Only Webinar">webinar</a> on May 14 from 2:00-3:00 p.m. ET to discuss the proposed rule.</li><li><strong>Assess </strong>the potential impact of the proposed payment and quality changes on your Medicare revenue and operations.</li><li><strong>Submit comments to CMS with your specific concerns by June 10 at </strong><a href="http://www.regulations.gov" target="_blank" title="Website to submit comments"><strong>www.regulations.gov</strong></a><strong>. </strong>A final rule will be published on or around Aug. 1, with TEAM currently scheduled to begin on Jan. 1, 2026.</li></ul><h2 class="text-align-center">FY 2026 TRANSFORMING EPISODE ACCOUNTABILITY MODEL PROPOSED RULE<br>TABLE OF CONTENTS<br> </h2><p><strong>Key Highlights ............................................................................................................... 1</strong><br><strong>AHA Take ........................................................................................................................ 1</strong><br><strong>What You Can Do ........................................................................................................... 2</strong><br><strong>Background .................................................................................................................... 4</strong><br><strong>Participation ................................................................................................................... 4</strong><br><strong>Use of Quality Measures In Payment Determination .................................................. 6</strong><br><strong>Pricing and Payment Methodology .............................................................................. 7</strong><br><strong>Health Data Reporting ................................................................................................. 12</strong><br><strong>Referral to Primary Care ...............................................................................................13</strong><br><strong>Waivers of Medicare Program Rules — SNF 3-DAY RULE ........................................13</strong><br><strong>Voluntary Decarbonization and Resilience Initiative..................................................13</strong></p><h2>Background</h2><p>CMS has tested episode-based payment models for over a decade through BPCI, CJR, and BPCI-A. In the <a href="/system/files/media/file/2024/09/transforming-episode-accountability-model-final-rule-advisory-9-16-2024.pdf" target="_blank" title="FY 2025 IPPS final rule">FY 2025 IPPS final rule</a>, CMS established a mandatory alternative payment model, TEAM, with the intent of building upon lessons learned from these past models. TEAM is scheduled to begin on Jan. 1, 2026.</p><p>CMS proposes several modifications to TEAM in this rule.</p><h2>PARTICIPATION</h2><p><strong>Participation Deferment for New Hospitals. </strong>CMS previously finalized two ways that hospitals could be designated as TEAM participants. First, if a hospital is located in one of 188 selected core-based statistical areas (CBSAs), it will be required to participate. In total, 741 <a href="https://www.cms.gov/team-model-participant-list" target="_blank" title="741 hospitals selected for TEAM">hospitals</a> are located in the CBSAs selected for TEAM and are therefore required to participate. Second, if a hospital participates in CJR or BPCI-A, it may opt into TEAM participation until the last day of the last performance period of the respective model. In both instances, hospitals will be required to participate in all five surgical episode categories for TEAM.</p><p>While CMS did not change these two underlying ways that hospitals participate in TEAM, it does propose a deferment period for certain new hospitals. Specifically, any new hospital established in a TEAM CBSA or any hospital that begins to meet the TEAM participant definition after Dec. 31, 2024, would be eligible for a one-year deferment from participation. These hospitals would be required to participate in TEAM starting on Jan. 1 of the subsequent performance year (PY) after the one-year period expires. For example, if a new hospital opens in a TEAM CBSA on June 1, 2026, which is in the middle of PY 1, then it would not be required to begin participation in TEAM until Jan. 1, 2028 (PY 3).</p><p>Conversely, for hospitals that stop meeting the definition of a TEAM participant once the model is underway, CMS would end participation as soon as the hospital stops meeting the definition. For example, if an inpatient PPS hospital changes status to a Critical Access Hospital, then the hospital would no longer be eligible for participation in TEAM, and participation would conclude the day prior to the status change. CMS proposes to notify hospitals that they are no longer participants within 30 days of the status change.</p><p>CMS also proposes to monitor markets for potential patient shifting between TEAM participants and non-participant hospitals.</p><p><strong>Participation Tracks.</strong><em> </em>CMS previously finalized three participation tracks for TEAM, with an optional one-year glidepath to two-sided risk (safety-net hospitals have a three-year glidepath). Details of the three tracks are below.</p><table border="1" cellspacing="0" cellpadding="0"><tbody><tr><td width="94"><p class="text-align-center"><strong>Track</strong></p></td><td width="144"><p class="text-align-center"><strong>Eligible Hospitals</strong></p></td><td width="52"><p class="text-align-center"><strong>PYs</strong></p></td><td width="86"><p class="text-align-center"><strong>Type of risk</strong></p></td><td width="76"><p class="text-align-center"><strong>Stop-Gain</strong></p></td><td width="71"><p class="text-align-center"><strong>Stop-Loss</strong></p></td><td width="101"><p class="text-align-center"><strong>Composite Quality Score (CQS) Adj.</strong></p></td></tr><tr><td rowspan="2" width="94"><p>Track 1</p><p>“Glidepath”</p></td><td width="144"><ul><li>All</li></ul></td><td width="52">PY1 Only</td><td width="86">Upside Only</td><td width="76">10%</td><td width="71">N/A</td><td width="101">10%</td></tr><tr><td width="144"><ul><li>Safety-net hospitals</li></ul></td><td width="52">PY1-PY3</td><td width="86">Upside Only</td><td width="76">10%</td><td width="71">N/A</td><td width="101">10%</td></tr><tr><td width="94"><p class="text-align-center">Track 2</p></td><td width="144"><ul><li>Safety-net</li><li>Rural</li><li>Medicare-dependent</li><li>Sole community</li><li>Essential access community</li></ul></td><td width="52">PY2-PY5</td><td width="86">Two-sided</td><td width="76">5%</td><td width="71">5%</td><td width="101"><p>10% for positive adjustments</p><p>15% for negative adjustments</p></td></tr><tr><td width="94"><p class="text-align-center">Track 3</p></td><td width="144"><ul><li>All others outside Track 1 and Track 2</li></ul></td><td width="52">PY1-PY5</td><td width="86">Two-sided</td><td width="76">20%</td><td width="71">20%</td><td width="101">10%</td></tr></tbody></table><p> </p><p><strong>Medicare-dependent Hospitals.</strong><em> </em>As noted, MDHs will be eligible for track 2 of the model. However, the MDH program is currently scheduled to expire on Sept. 30, 2025. For FY 2026, CMS proposes that participants who are classified as MDHs would be eligible for track 2 participation as long as the MDH program is active at the time the participation track selections are due to CMS. The form, manner and dates for participants to select tracks are not specified in the rule but will be provided by CMS. For example, if CMS requests participants to select tracks by Nov. 15, 2026, for PY 2 and the MDH program was scheduled to expire on Dec. 31, 2026, then TEAM participants with an MDH designation that select track 2 prior to Nov. 15, 2026, would be eligible for track 2 in PY 2 regardless of whether the MDH program expired in 2026. In addition, the agency believes the impacts to be small, as many of the MDHs would still be eligible for track 2 given their location in rural areas, even if the MDH program were to expire. Specifically, CMS estimates that of the 741 hospitals that were selected for TEAM, 25 have an MDH designation, and of the 25, 21 would remain eligible for track 2 for other factors (such as being located in a rural area). The agency requests feedback on this proposal.</p><p><strong>Indian Health Service Hospitals. </strong>In the FY 2025 inpatient PPS final rule<strong>, </strong>CMS did not exempt Indian Health Service (IHS) hospitals from participating in TEAM. However, the agency did receive questions about eligibility since IHS hospitals are not paid under the outpatient PPS, and two of the TEAM episode categories (lower extremity joint replacement and spinal fusion) include outpatient episodes. The agency considered but did not propose several alternatives for IHS hospitals. For example, CMS considered but did not propose excluding IHS hospitals from episode categories that may be initiated in both inpatient and outpatient settings. The agency also considered but did not propose excluding IHS hospitals from the model. CMS seeks comments on potential options for IHS hospitals.</p><h2>USE OF QUALITY MEASURES IN PAYMENT DETERMINATION</h2><p>Last year, CMS finalized proposals to tie the performance of selected quality measures to existing hospital quality reporting and value programs (including the Hospital Inpatient Quality Reporting (IQR) program and Hospital Acquired Condition (HAC) reporting program). Specifically, the agency finalized that for the first TEAM PY, CMS will use the following three measures:</p><ul><li>For all TEAM episodes: Hybrid Hospital-Wide All-Cause Readmission Measure with Claims and Electronic Health Record Data (CMIT ID #356).</li><li>For all TEAM episodes: CMS Patient Safety and Adverse Events Composite (CMS PSI 90) (CMIT ID #135).</li><li>For LEJR episodes: Hospital-Level Total Hip and/or Total Knee Arthroplasty (THA/TKA) Patient Reported Outcome-Based Performance Measure (PRO-PM) (CMIT ID #1618).</li></ul><p>Beginning with the second PY, CMS finalized that it will no longer use the PSI 90 measure, but will instead add three other patient safety-focused measures applicable to clinical episodes:</p><ul><li>Hospital Harm eCQM: Postoperative Respiratory Failure (CMIT ID# 1788).</li><li>Hospital Harm eCQMs: Falls with Injury (CMIT ID #1518).</li><li>30-day death rates among surgical inpatients with preventable complications (Failure to Rescue, CMIT ID #134).</li></ul><p>In the FY 2026 proposed rule, CMS proposes several changes to the quality measure set, as outlined below.</p><p><strong>Alignment of Hybrid Hospital-Wide Readmission Measure to Hospital IQR Program. </strong>To better align the TEAM hospital-wide readmission (HWR) measure performance period with the Hospital IQR program, CMS proposes to change the performance period for this measure for PY 1.</p><p>In the CY 2025 outpatient PPS final rule, CMS delayed mandatory reporting of the HWR measure for the Hospital IQR program. Specifically, mandatory reporting of the HWR measure in the Hospital IQR program will begin with the period of July 1, 2025, through June 30, 2026. This would impact TEAM PY1 as the TEAM HWR performance period for PY1 was July 1, 2023, through June 30, 2024. </p><p>CMS proposes to use the mandatory reporting period from July 1, 2025, to June 30, 2026, as the TEAM PY1 performance period for the HWR measure. The agency seeks feedback on this proposal and others that should be considered.</p><p><strong>Information Transfer Patient Reported Outcome-based Performance Measure (PRO-PM). </strong>In the FY 2025 IPPS final rule, CMS indicated a desire to incorporate more patient-reported outcomes measures into TEAM. The agency also wanted to add measures capturing care in the outpatient setting for lower extremity joint replacement (LEJR) and spinal fusion episodes.</p><p>In this rule, the agency proposes to add the Information Transfer PRO-PM measure to the quality measure set. CMS proposes to include this measure starting in PY 3 (2028). The agency indicated that this timing would align with reporting for the hospital outpatient quality reporting (OQR) program, as the Information Transfer PRO-PM is scheduled for mandatory reporting beginning in CY 2027.</p><p><strong>Approach for When TEAM Participant Has No Quality Measure Performance Data. </strong>In the FY 2025 IPPS final rule, CMS did not address how quality measures would be adjusted in instances where quality measure performance data are not available for certain measures. For example, for new hospitals or for hospitals that are not voluntarily reporting the Hospital Harm-Falls with Injury or Hospital Harm-Postoperative Respiratory Failure measures, the agency did not address how quality scores would be adjusted.</p><p>In this rule, CMS proposes to assign a neutral quality score for participants who have no or incomplete quality measure data for specific quality measures. Specifically, participants would be assigned a scaled quality measure score of 50 for those measures, which is the midpoint on the Composite Quality Score scale of 0-100. The agency seeks feedback on this proposal.</p><h2>PRICING AND PAYMENT METHODOLOGY</h2><p>To calculate target prices by episode type and region, TEAM will use three years of baseline data trended forward prospectively to the performance year. Episodes will be capped at the 99th percentile for each episode type and across nine regions (identified by U.S. census divisions) to exclude outlier spending. Average standardized spending for each episode type in each region will be used as the benchmark price.</p><p>This rule proposes several policies for TEAM pricing and payment methodology.</p><p><strong>Accounting for Future Changes to MS-DRGs and HCPCS. </strong>In the FY 2025 inpatient PPS final rule, CMS acknowledged that changes to Medicare-severity Diagnosis-related Groups (MS-DRGs) and Healthcare Common Procedure Coding System (HCPCS) may impact episode pricing. Specifically, the agency received comments regarding modifications to the spinal fusion episode category, including the deletion of MS-DRGs 453-455 and the addition of eight new MS-DRGs, and how these modifications would be addressed in the TEAM. The agency indicated it would issue subsequent rulemaking to address this issue.</p><p>As such, CMS proposes a three-step approach to account for MS-DRG or HCPCS changes by remapping and adjusting episode types during the baseline period to estimate performance year costs. Specifically, the three-step process would include:</p><ul><li><u>Step 1.</u> Identify the diagnosis or procedure codes being moved from one MS-DRG to another, and then map these codes to the new MS-DRG or HCPCS code. In other words, baseline period episodes would be reassigned to the MS-DRG or HCPCS they would have received had the episode occurred in the PY. Baseline inpatient stays and outpatient procedures would be grouped into three categories:</li></ul><p>1) existing MD-DRGs or HCPCs that would be deleted and mapped to new or existing MS-DRGs.</p><p>2) existing MS-DRGs or HCPCS that would be retained, but portions of them would be mapped to new or existing MS-DRGs or HCPCS.</p><p>3) MS-DRGs or HCPCS where there would be no changes.</p><ul><li><u>Step 2.</u><em> </em>Construct episodes and target prices using the remapped MS-DRGs and HCPCSs.</li><li><u>Step 3.</u> Adjust standardized allowed amounts used in target price calculations to account for changes in fee-for-service rates between the baseline period and performance year due to changes in MS-DRG and HCPCS weights. CMS would use a scaling factor to account for differences in the relative weights of the original and re-mapped MS-DRGs.</li></ul><p>Unlike BPCI-A, CMS is not proposing a fourth step to account for setting-specific update factors. Additionally, the agency is not proposing preliminary target price updates based on FY payment rule updates. Therefore, the three-step process may not address MS-DRG changes that are implemented in the last quarter of a calendar year or the TEAM performance year.</p><p><strong>U.S. Territories and Census Division 9.</strong> CMS will provide target prices for each MS-DRG/HCPCS and region. This will result in 261 benchmark prices (29 MS-DRG/HCPCS episode types and nine regions). Benchmark prices will be calculated using all hospitals in a region, regardless of TEAM participation status. This rule proposes to formalize that hospitals in the five U.S. territories (including American Samoa, Guam, the Northern Mariana Islands, Puerto Rico and the U.S. Virgin Islands) will be grouped in Census Division 9 for regional target price construction.</p><p><strong>Calculation and Application of Normalization Factor. </strong>Last year, CMS finalized a policy to calculate a prospective normalization factor during the creation of preliminary target prices. This will be calculated as the ratio of the average total risk-adjusted preliminary target price to the average total non-risk-adjusted preliminary target price for each episode type.</p><p>In this rule, CMS proposes to update language to clarify that the prospective normalization factor will be calculated using the benchmark prices (that is, the average non-risk-adjusted preliminary benchmark price divided by the average risk-adjusted preliminary benchmark price) rather than target prices.</p><p>Additionally, CMS proposes to calculate normalization factors at the regional level as well as at the MS-DRG and HCPCS levels. Specifically, the agency proposes to calculate normalization factors as the average regional non-risk-adjusted benchmark price divided by the average regional risk-adjusted preliminary benchmark price for each MS-DRG/HCPCS episode type. This would produce a unique normalization factor for each region and MS-DRG/HCPCS episode type for a total of 261 normalization factors (versus the 29 normalization factors previously proposed).</p><p>Finally, CMS proposes to provide two separate preliminary target prices to participants: 1) the regional average target price for each MS-DRG/HCPCS episode type before application of risk adjustment or normalization factors and 2) a TEAM participant specific preliminary target price including the TEAM participant’s average risk adjustment factors and the regional MS-DRG/HCPCS normalization factors.</p><p><strong>Prospective Trend Factor.</strong> CMS previously finalized its policies for a prospective trend factor and added a 3% capped retrospective trend factor as a guardrail. However, it now proposes several changes to the prospective trend factor. First, CMS proposes to change the calculation of the prospective trend factor from a percentage change between baseline year 1 (BY1) and BY3 to a log-linear model that would fit the model to logarithmically transformed values of average regional MS-DRG spending for each of the BYs. Second, the agency adds two years of episode spending data to the calculation of the prospective trend factor. The two years would be the two years immediately prior to the three-year baseline period. The two additional years would only be used for the calculation of the prospective trend factor.</p><p align="left">In addition, the agency proposes to use a blend of regional and national trend factors in the calculation of preliminary target prices. The national prospective trend factor would be calculated in the same manner as the regional trend factors using a linear regression of logarithmically transformed national average MS-DRG spending.</p><p>Finally, CMS proposes changes to the application of the outlier spending cap. In the FY 2025 inpatient PPS final rule, CMS finalized that the high-cost outlier spending cap would be applied to the 99<sup>th</sup> percentile of regional spending for a given MS-DRG/HCPCS episode type in a given region <em>across all 3 years of the baseline period. </em>However, it now proposes to calculate the 99<sup>th</sup> percentile for a given MS-DRG/HCPCS episode type in a given region for <em>each of the baseline and trend years</em>. The agency requests feedback on this proposed change as well as other approaches to calculating the 2-year trend factor and weighting the trend factor.</p><p><strong>Standardizing Area Deprivation Index (ADI).</strong> Last year, CMS finalized a social need risk adjustment factor to account for multiple beneficiary markers of social risk. This would be a binary measure if beneficiaries met any one of three categories to include:</p><ul><li>Dual-eligibility status.</li><li>Residing in a census block group that exceeded the threshold for ADI (80th  percentile nationally or 8th decile for the state).</li><li>Eligibility for Part D Low-income Subsidy.</li></ul><p>CMS proposes several changes to this social-need risk adjustment factor. First, the agency proposes to rename the social need risk adjustment factor to the beneficiary-economic risk adjustment variable. Additionally, CMS proposes to modify the deprivation index methodology from the ADI to the Community Deprivation Index (CDI). The CDI would be a factor-weighted composite measure of 18 variables from the Census Bureau and is being constructed as part of the Accountable Care Organization Realizing Equity, Access, and Community Health model. The agency proposes to maintain the use of percentile rankings relative to the nation and the 80th percentile threshold for the measure.</p><p>With the proposed transition to the CDI, the agency also proposes to only use national-level CDI rankings as opposed to national and state-level rankings, as would have been the case with the ADI.</p><p>The agency seeks comment on renaming the social need risk adjustment factor to the beneficiary-economic risk adjustment variable and transitioning from ADI to the CDI. CMS also requests feedback on whether it should remove dual eligibility from the economic risk adjustment factor.</p><p><strong>Hierarchical Condition Categories (HCC) in Risk Adjustment. </strong>CMS previously proposed but did not finalize the look-back period for the HCC to be used in the TEAM risk adjustment calculation. As such, it now has a 180-day look-back for each beneficiary beginning the day prior to the anchor hospitalization or anchor procedure. CMS also proposes that the beneficiary must meet criteria for TEAM inclusion for the entire 180-day look-back period.</p><p>The agency considered several other timeframes, including 90-day, 120-day, 270-day or 365-day look-back periods. The agency did not consider periods longer than one year, although it acknowledges that there is limited research about the most appropriate timeframe for HCC look-back. Therefore, CMS solicits feedback on the proposed 180-day look-back period and alternatives that should be considered.</p><p>The agency also proposes to use HCC version 28 instead of HCC version 22. HCC version 22 was the version used for BPCI-A and is the basis for which the TEAM risk adjustment was originally constructed. However, it is not the most recent version and was based on ICD-9 data. CMS proposes an updated mapping of episode category-specific risk adjustors in table XI.A.-011 (page 1018 of the display copy of the rule).</p><p><strong>Low-volume Thresholds. </strong>CMS previously proposed that participants with fewer than 31 episodes across all episode categories would still be included in the model but would be subject to track 2 beginning in PY 2 (lower stop-gain/stop-loss thresholds). However, based on stakeholder comments that this policy was insufficient, it did not finalize this low-volume hospital policy and instead indicated it would propose a new policy in future rulemaking.</p><p>In this rule, CMS proposes to have no low volume policy given that PY1 is upside only. It is seeking comments on potential future low-volume policies, including:</p><ul><li>A uniform low-volume threshold for across episode categories in the baseline period for a given PY (similar to BPCI-A).</li><li>Different low-volume thresholds for each episode category. CMS stated it is considering 91, 61, 51, 41, 21 and 11 cases.</li><li>Limiting the scope of the low-volume policy to safety net and rural hospitals only.</li><li>Not holding TEAM participants that meet low-volume criteria accountable for that episode category for the performance year.</li><li>Lowering stop-loss/stop-gain limits for low-volume hospitals (e.g., to 5%, 3%, 2% or 1%).</li></ul><p><strong>Aligning Date Range in the Baseline and Performance Years and Timing of Reconciliation. </strong>In the FY 2025 IPPS final rule, CMS finalized that TEAM preliminary target prices would be based on a 3-year rolling baseline period with episodes attributed based on the episode start date. So, an episode beginning in December 2022 with a discharge date of January 2023 would be attributed to BY 1 for PY 1. However, for PYs, CMS finalized that attribution would be based on the date of discharge for the anchor hospitalization or procedure to assign target prices. </p><p>To better align BY and PY methodologies, the agency proposes to use the same methodology for baseline year attribution to calculate preliminary target prices and align attribution based on the date of discharge. For example, an episode with an anchor hospitalization beginning in December 2022 with an anchor hospitalization discharge date in January 2023 would be included in the baseline for both PY1 (BY2 of baseline from Jan. 1, 2022, to Dec. 31, 2024) and PY2 (BY1 of baseline from Jan. 1, 2023, to Dec. 31, 2025).</p><p><strong>Converting Target Prices and Reconciliation Amounts to Real Dollars. </strong>TEAM uses standardized allowed dollar amounts in the calculation of performance year spending and reconciliation, as opposed to real nominal dollar amounts reflected on claims. This removes adjustments to payment amounts for Medicare incentive programs (like the HAC reduction program) and geographic factors (like the hospital wage index). However, the agency did not create policies for converting standardized target prices and reconciliation amounts back to real dollars. As such, CMS requests feedback on whether alternatives should be considered.</p><p>Similarly, CMS requests feedback on whether it should convert post-episode spending amounts to real dollars. In the FY 2025 inpatient PPS final rule, CMS finalized that if a TEAM participant’s average 30-day post-episode spending is greater than three standard deviations above the regional average 30-day post-episode spending, then the amount above the threshold would be subtracted from the reconciliation amount for that PY. In the FY 2026 inpatient PPS proposed rule, CMS solicits feedback on whether the post-episode spending amounts should be converted to real dollars to maintain consistency with the target price and reconciliation. In instances where a TEAM participant’s average post-episode spending in the MS-DRG/HCPCS episode type exceeds the region’s threshold, CMS solicits feedback as to whether or not the amount above the threshold should be converted from standardized to real dollars using a hospital-level real-to-standardized spending ratio. </p><p>Finally, the agency requests feedback on its consideration to determine post-episode spending at the MS-DRG-<em>hospital</em> level rather than the episode spending level. The agency stated that this was considered because average post-episode spending is more representative of consistent patterns in the delay of medically necessary services in the post-discharge period by a hospital, and hospitals do not have the same incentives to not exceed expected post-episode spending that they have with in-episode spending.</p><h2>HEALTH DATA REPORTING</h2><p>CMS proposes several changes in health data reporting to reflect administration priorities and address concerns about placing additional burdens on TEAM participants in a mandatory model.</p><p>Specifically, the agency proposes to:</p><ul><li>Remove the voluntary health equity plan and the health-related social needs data policies from TEAM, including all references to health equity plans.</li><li>Remove the “health equity reporting” title and replace it with “health data reporting.”</li><li>Remove the definition for “health equity goal,” “health equity plan,” “health equity plan strategy,” “health equity plan performance measure,” and “underserved community.”</li><li>Remove the voluntary collection of health-related social needs screening and reporting, including the screening for social drivers of health measure and the screen-positive rate for social drivers of health measure.</li><li>Update the name of a beneficiary identifiable data variable from “gender” to “sex.”</li></ul><p>CMS does not propose any changes to the voluntary collection of demographic data. While the agency does not specify the exact variables that TEAM participants will report for demographic data collection, the agency does clarify that it will not be collecting variables such as sexual orientation, race, ethnicity or gender identity.</p><h2>REFERRAL TO PRIMARY CARE</h2><p>Currently, TEAM participants will be required to include a referral to a supplier of primary care services as part of hospital discharge planning. Referrals will need to be made prior to discharge from the anchor hospitalization or procedure and will need to be in accordance with beneficiary choice requirements. However, the agency seeks feedback on whether or not requiring beneficiaries to be referred back to a supplier of primary care services with whom they have an established relationship could disrupt competition and/or limit access to high-value care.</p><h2>WAIVERS OF MEDICARE PROGRAM RULES — SNF 3-DAY RULE</h2><p>TEAM includes a waiver of the three-day SNF rule to allow TEAM participants to send eligible TEAM beneficiaries to qualified SNFs without meeting the requirement for a three-day inpatient hospital stay. This waiver excludes swing beds. However, stakeholders have continued to express concerns surrounding post-acute access in rural and underserved areas. As such, CMS proposes to allow TEAM participants to use the SNF three-day waiver for TEAM beneficiaries discharged to hospitals and critical access hospitals providing post-acute care under swing bed arrangements. CMS clarifies that the minimum three-star rating requirement applies only if the provider furnishing SNF services is eligible for the CMS five-star quality rating system.</p><h2>VOLUNTARY DECARBONIZATION AND RESILIENCE INITIATIVE</h2><p><u></u></p><p>CMS proposes to remove the voluntary Decarbonization and Resilience Initiative from TEAM.</p><h2>FURTHER QUESTIONS</h2><p>Please contact Jennifer Holloman, AHA’s senior associate director of physician and alternative payment policy, at (202) 626-2320 or <a href="mailto:jholloman@aha.org">jholloman@aha.org</a>.</p></div><div class="col-md-4"><a href="/system/files/media/file/2025/05/fy-2026-transforming-episode-accountability-model-proposed-rule-advisory-5-7-2025.pdf"><img src="/sites/default/files/2025-05/cover-fy-2026-transforming-episode-accountability-model-proposed-rule-advisory-5-7-2025.png" data-entity-uuid data-entity-type="file" alt="Advisory Cover Image" width="NaN" height="NaN"></a></div></div></div> Wed, 07 May 2025 11:11:54 -0500 Quality Measures /news/perspective/2025-03-14-prioritizing-patient-safety-and-quality-care-every-day-everyone <p>It’s hard to believe, but this week marks five years since President Trump declared the COVID-19 pandemic a national emergency and related lockdowns across the globe turned the world we knew upside down.</p><p>We remember all too well how the surging pandemic changed the way we lived, worked, shopped, educated our children and affected so many other aspects of everyday life.  </p><p>We also remember the bravery, courage and heroics that health care teams across the country demonstrated each and every day as they cared for their friends and neighbors during the most challenging conditions.</p><p>Former AHA Board Chair Mindy Estes, M.D., who helped lead and inspire the field during the first year of COVID-19, said during that difficult period, “no virus can defeat the human spirit. Because we are stronger than this monumental moment in history, and we are not giving up the fight.”</p><p>Her successor, Rod Hochman, M.D., who served as AHA Chair in 2021, has described the performance of hospitals and health systems during the pandemic as the “finest hour” in American health care history.</p><p>While the nation’s daily recognitions of our caregivers have stopped, our respect and admiration for all the caregivers who served and continue to serve on the front lines caring for patients and communities will never be forgotten.</p><p>The same level of commitment to patient safety and delivering quality care continues today. Every day in every hospital and health system across America, dedicated care teams strive to deliver safe, high-quality care to every patient, continually identifying what drives better outcomes and then implementing changes to improve patient care.</p><p>This week, which is <a href="/patient-safety-awareness-week" target="_blank" title="Paient Safety Awareness Week">Patient Safety Awareness Week</a>, the AHA released a <a href="/news/headline/2025-03-12-new-report-shows-improvements-patient-safety-and-workforce-resilience" target="_blank" title="AHA Press Ganey Report">report</a> with Press Ganey showing that patients and the health care workforce report improvements in safety, care quality and resilience.</p><p>Some key findings include:</p><ul><li><strong>13 million</strong> patients surveyed after hospital stays report improvements in their <strong>overall care experience and perception of safety.</strong></li><li>Surveys of <strong>1.7 million members of the</strong> <strong>health care workforce show a rebound in their reported experience, resilience and perceptions of safety culture, </strong>following the enormous strain of the COVID-19 pandemic.</li><li>Alongside improvements in safety culture, patient experience and employee experience, there were <strong>improvements in key safety outcomes like falls and infections </strong>—<strong> across more than</strong> <strong>25,000 units in 2,430 hospitals</strong>.</li></ul><p>The report demonstrates continued positive trends for hospitals and health systems that were outlined in a <a href="/guidesreports/2024-09-12-new-analysis-shows-hospitals-performance-key-patient-safety-measures-surpassing-pre-pandemic-levels" target="_blank" title="AHA, Vizient Report">September 2024 report we released in conjunction with Vizient</a> that showed a decrease in adverse patient safety events along with increasing health care screenings — even as hospitals are caring for more higher acuity patients.</p><p>The reports are part of the AHA’s Patient Safety Initiative, which was launched in 2023 to reaffirm hospital and health system leadership and commitment to patient safety. The initiative provides hospitals with tools and data to advance patient safety, offers a platform for sharing their stories of improvement with peers, and highlights examples of innovation that support, spread and sustain safety improvement.</p><p>You can see more about these efforts on <a href="/aha-patient-safety-initiative" target="_blank" title="AHA Patient Safety Initiative web page">AHA’s webpage</a>, where among other resources you can view <a href="/leading-safety-aha-quest-quality-series#Q4QVideoSeries" target="_blank" title="Leading for Safety video series">Leading for Safety, a video series</a> hosted by Dr. Estes that explores how health care leaders can drive safer, higher-quality care by fostering a culture of safety and innovation.</p><p>Health care is about people caring for other people.<strong> </strong>While hospitals and health systems continue to make progress on their efforts to advance quality and safety, we know that the journey is far from over. Hospitals and health systems will never stop working to advance patient safety and quality. It has been — and will always be — our field’s top priority.</p> Fri, 14 Mar 2025 08:22:09 -0500 Quality Measures /education-events/enhancing-patient-safety-understanding-and-leveraging-unit-safety-score-improved-outcomes-dec-11 <div class="TTevent"> /* Forces the event Content Type to be 100% */ .container .row .col-md-8{ width: 100% } .event-registration-link a{ margin-left: auto; margin-right: auto; display: block; text-align: center; } .event-registration-link a.btn-block { max-width: 300px; } .TTevent h3{ color:#002855; } .TTeventBonus{ color:#9d2235; font-weight:700; font-style: italic; } .TTeventdate{ font-weight: 700; font-size: 18px; color: #555555bb; line-height: 20px; } .TTeventSponsor img{ max-height:100px; } <p class="TTeventdate">December 11, 2024</p><p>The Unit Safety Score provides a comprehensive, weighted measure of inpatient safety performance by tracking eleven key domains across harm and best practice events. Calculated on a rolling three-month basis, the score is designed to help health care nursing units identify and address preventable patient safety issues, ensuring accountability and continuous improvement. Each domain is weighted to reflect its importance in patient safety, with harm events indicating hospital-acquired risks and best practice events highlighting preventive actions. To maintain a patient-centered approach, the score also tracks the number of individual patients impacted, supporting a holistic view of safety efforts and outcomes.</p><h4>Learning Objectives:</h4><ul><li>Explain the Components of the Unit Safety Score</li><li>Demonstrate the Calculation of the Weighted Unit Safety Score</li><li>Encourage Ongoing Engagement with the Unit Safety Score for Continuous Improvement</li></ul><div class="row"><div class="col-md-5"><h4>Speaker:</h4><ul><li><strong>LeaAnn Teague, MBA, MT(ASCP), SBB</strong><br><em>Sr. Director of Performance Improvement,</em> Our Lady of the Lake Health</li></ul><p class="text-align-center"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2024/12/AHA_Team_Training_Webinar_Slides_Dec_2024.pdf" target="_blank">Download the slides</a></p> <div class="col-md-6"> <h4>SPONSORED BY:</h4> </div> <div class="col-md-6"> <p><a href="https://q-reviews.com/q-reviews/" target="_blank"><img alt="Quality Reviews logo" data-entity-type="" data-entity-uuid="" src="/sites/default/files/2021-01/Quality_Reviews_transparent_logo_200.png" /></a></p> </div> </div>--></div><div class="col-md-7"><div></div></div></div></div><div class="raw-html-embed"> <div data-embed-button="webform_embed" data-entity-embed-display="view_mode:webform.token" data-entity-type="webform" data-entity-uuid="0b43a680-6f37-4d3f-9bf9-4cd6c7c7ddc5" data-langcode="en" data-entity-embed-display-settings="[]" class="embedded-entity"> <div id="edit-processed-text" class="js-form-item form-item js-form-type-processed-text form-item- js-form-item- form-no-label"> <div class="TTwebinarHide"> .webform-submission-form { max-width: 700px; } .TTwebinarHide{ display:none } .event-content.panel .TTwebinarHide { display:block; background-color: #fff; padding: 15px 15px 15px 15px; border: solid 2px #307FE2; text-align: center; } <p><a href="/center/team-training">Team Training</a> offers a variety of webinars - view our <a href="/center/team-training/webinars">current offering(s)</a> or browse the <a href="/center/team-training/webinars/library">library</a>.</p> </div> </div> </div> </div> Fri, 08 Nov 2024 10:44:08 -0600 Quality Measures <div class="container"><div class="row"><div class="col-md-8"><p>On June 26, the Centers for Medicare & Medicaid Services (CMS) issued its calendar year (CY) 2025 <a href="https://www.federalregister.gov/documents/2024/07/03/2024-14254/medicare-program-calendar-year-cy-2025-home-health-prospective-payment-system-hh-pps-rate-update-hh" target="_blank" title="Federal Register: Medicare Program; Calendar Year (CY) 2025 Home Health Prospective Payment System (HH PPS) Rate Update; HH Quality Reporting Program Requirements; HH Value-Based Purchasing Expanded Model Requirements; Home Intravenous Immune Globulin (IVIG) Items and Services Rate Update; and Other Medicare Policies">proposed rule for the home health (HH) prospective payment system (PPS)</a>. Comments are due Aug. 26, and a final rule is expected around Nov. 1. New policies would generally be effective Jan. 1, 2025.</p><div class="panel module-typeC"><div class="panel-heading"><h2>Key Highlights</h2><p>The proposed HH rule would:</p><ul><li>Reduce net HH payments by an estimated 1.7% or $280 million, after all policy changes, compared to estimated CY 2024 payments. This reduction includes:<ul><li>A permanent behavioral adjustment (applied to the 30-day episode payment rate only) that is expected to reduce payments by 3.6%;</li><li>A 3.0% market basket update, reduced by a negative 0.5% productivity adjustment; and</li><li>An estimated 0.6% decrease in payments due to changes in outlier payments.</li></ul></li><li>Require HH agencies to report four new patient assessment items in the HH agency Outcome and Assessment Information Set (OASIS) under the social determinants of health category beginning with CY 2027.</li><li>Add a new standard within the Medicare Conditions of Participation that would require HH agencies to develop, implement and maintain a patient acceptance to service policy that is applied consistently to each prospective patient referred for home health care.</li></ul><p>The proposed rule also contains a provision that would adopt requirements for long term care (LTC) facilities to report certain data elements related to respiratory elements as part of their infection control programs.</p></div></div><h2>AHA Take</h2><p>HH agencies (HHAs) are an important part of the care continuum for Medicare beneficiaries and often are key to enabling hospital partners to safely discharge patients home. CMS’ continued application of such large behavioral adjustments may threaten access to HH care for beneficiaries and, in doing so, also negatively impact care for other patients in need of acute hospital services by preventing hospitals and health systems from discharging patients in a timely manner. The AHA continues to urge CMS to reconsider its approach to these payment reductions to ensure access for patients in need of continued recovery at home.</p><h2>What You Can Do</h2><ul><li>Share this advisory with your senior management team to examine the impact these payment changes would have on your organization in CY 2025.</li><li>Submit a comment letter on the proposed rule to CMS by Aug. 26 explaining the rule’s impact on your patients, staff, facility and local health care partners.</li></ul><h2>Proposed CY 2025 Payment Updates</h2><p>The rule’s proposed net impact is a decrease of 1.7%, or $280 million, in payments after all policy changes, compared to CY 2024. This includes a proposed market basket update of 3.0%, reduced by a statutorily required 0.5% productivity factor ($415 million net increase). CMS’ proposed 4.07% behavioral adjustment (applied to the 30-day payment rate) would reduce payments by an estimated 3.6% overall, or $590 million. In addition, CMS estimates that there would be an 0.6% decrease in overall payments ($100 million) as a result of an updated fixed-dollar loss ratio for outlier payments.</p><p>CMS also provides an estimate of impact by type of HHA. It estimates that freestanding HHAs would see a 1.6% decrease, but facility-based HHAs would receive a 1.9% decrease relative to CY 2024. In addition, HHAs located in rural areas would receive a 0.3% decrease, while those in urban areas are estimated to realize a 1.8% decrease. The difference in rural and urban providers is largely attributable to changes in wage index levels (discussed further in the <a href="/system/files/media/file/2024/07/Regulatory-Advisory-Home-Health-PPS-Proposed-Rule-for-CY-2025.pdf" target="_blank" title="Click here to download the Regulatory Advisory: Home Health PPS Proposed Rule for CY 2025 PDF."><strong>complete regulatory advisory PDF</strong></a>).</p></div><div class="col-md-4"><p><a href="/system/files/media/file/2024/07/Regulatory-Advisory-Home-Health-PPS-Proposed-Rule-for-CY-2025.pdf" target="_blank" title="Click here to download the Regulatory Advisory: Home Health PPS Proposed Rule for CY 2025 PDF."><img src="/sites/default/files/inline-images/Page-1-Regulatory-Advisory-Home-Health-PPS-Proposed-Rule-for-CY-2025-20240723.png" data-entity-uuid="73fbb8b0-d9d9-4021-a49a-f9ed38f67614" data-entity-type="file" alt="Regulatory Advisory: Home Health PPS Proposed Rule for CY 2025 page 1." width="695" height="900"></a></p></div></div></div> Mon, 22 Jul 2024 11:50:22 -0500 Quality Measures <p>The Center for Medicare & Medicaid Innovation (CMMI) on April 10th proposed a new mandatory bundled payment model called the Transforming Episode Accountability Model (TEAM). The proposed payment model, included as part of the <a href="/news/news/2024-04-10-cms-issues-hospital-ipps-proposed-rule-fy-2025" target="_blank">CY2025 Inpatient Prospective Payment System (IPPS) proposed rule</a>, expands upon previous episode-based payment models like the Comprehensive Care for Joint Replacement (CJR) model and the Bundled Payments for Care Improvement Advanced (BPCI-A) model. </p><p>On May 7, 2024, the AHA policy experts discussed the Transforming Episode Accountability Model (TEAM) in a webinar. Members can <a href="https://aha-org.zoom.us/rec/share/mp8VkV31Gw8obAVi3gu1mm1UTqYPYe8hchKvhHR2RXFt7yCHDvYceJE3hci65QYe.n0nu8qfOXFX8HfLW" target="_blank">View Recording</a><a href="https://zoom.us/rec/play/Zs0JYYDvxMYB26eZiU7lu3YJXxC9Mq1S-m7dRqIQInfGGYqmGeZXJ8US2EergbTyOg-KbpKNZ889TxuE.KmXemA8BTZtCBpYQ?autoplay=true" target="_blank"> </a>and <a href="/system/files/media/file/2024/05/TEAM%20Model%20Member%20Webinar%20Slides.pdf" download="file" target="_blank" title="Slides ">Download Slides</a> from the event. </p> Wed, 08 May 2024 10:43:39 -0500 Quality Measures /education-events/whats-data-got-do-it-why-data-mission-critical-your-teamstepps-success-dec-13 <div class="TTevent"> /* Forces the event Content Type to be 100% */ .container .row .col-md-8{ width: 100% } .event-registration-link a{ margin-left: auto; margin-right: auto; display: block; text-align: center; } .event-registration-link a.btn-block { max-width: 300px; } .TTevent h3{ color:#002855; } .TTeventBonus{ color:#9d2235; font-weight:700; font-style: italic; } .TTeventdate{ font-weight: 700; font-size: 18px; color: #555555bb; line-height: 20px; } .TTeventSponsor img{ max-height:100px; } <p class="TTeventdate">December 13, 2023</p><p>Let’s be honest – we have a “love-hate” relationship with data. We can get lost in the drudgery of our dashboards and lose sight of data’s power to inspire. Every organization has its pain points. Connecting our stories with measurement drives understanding of our challenges and empowers an organization’s collective “why.” When you discover the data you have and get intentional about measurement, suddenly the work you do daily takes on new meaning. You have proof that the culture change you’re pursuing is making a difference in real time.</p><p>So, let’s talk data. We start this webinar by examining why data and the story it tells are “mission critical” to TeamSTEPPS success. Next, we look at some examples that demonstrate the power of data to inform and inspire. We also review some of the “nuts and bolts” of measurement by examining Kirkpatrick’s model of measurement and the importance of both outcome and process measures for assessing TeamSTEPPS implementation success.</p><h4>Learning Objectives:</h4><ul><li>Describe the importance of measurement in supporting your personal and organizational “why”</li><li>Describe the Kirkpatrick model as applied to TeamSTEPPS implementation evaluation</li><li>Identify the link between process and outcome measures for tracking TeamSTEPPS success</li><li>Discuss the national implication of data collection surrounding TeamSTEPPS implementation</li></ul><div class="row"><div class="col-md-5"><h4>Speakers:</h4><ul><li><strong>Rhonda Fischer, RN, BSN, CEN</strong><br><em>Team Training Clinical Program Lead,</em> ���������� Association</li><li><strong>Tonya Martino, RN, BSN, ND</strong><br><em>Clinical Director of Team Performance,</em> WWAMI Institute for Simulation in Healthcare (WISH), University of Washington</li><li><strong>Stacy Norton, MD, FACOG</strong><br><em>Chief-of-Staff,</em> Houston Methodist Willowbrook</li></ul><p class="text-align-center"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2023/12/AHA_Team_Training_Webinar_Slides_Dec_2023.pdf" target="_blank">Download the slides</a></p> <div class="col-md-6"> <h4>SPONSORED BY:</h4> </div> <div class="col-md-6"> <p><a href="https://q-reviews.com/q-reviews/" target="_blank"><img alt="Quality Reviews logo" data-entity-type="" data-entity-uuid="" src="/sites/default/files/2021-01/Quality_Reviews_transparent_logo_200.png" /></a></p> </div> </div>--></div><div class="col-md-7"><div></div></div></div></div> <div data-langcode="en" data-entity-type="webform" data-entity-uuid="0b43a680-6f37-4d3f-9bf9-4cd6c7c7ddc5" data-embed-button="webform_embed" data-entity-embed-display="view_mode:webform.token" data-entity-embed-display-settings="[]" class="embedded-entity"> <div id="edit-processed-text--2" class="js-form-item form-item js-form-type-processed-text form-item- js-form-item- form-no-label"> <div class="TTwebinarHide"> .webform-submission-form { max-width: 700px; } .TTwebinarHide{ display:none } .event-content.panel .TTwebinarHide { display:block; background-color: #fff; padding: 15px 15px 15px 15px; border: solid 2px #307FE2; text-align: center; } <p><a href="/center/team-training">Team Training</a> offers a variety of webinars - view our <a href="/center/team-training/webinars">current offering(s)</a> or browse the <a href="/center/team-training/webinars/library">library</a>.</p> </div> </div> </div> Wed, 15 Nov 2023 14:55:24 -0600 Quality Measures /lettercomment/2023-08-17-aha-responds-cms-episode-based-payment-model-request-information <p>August 17, 2023</p> <p>The Honorable Chiquita Brooks-LaSure<br /> Administrator<br /> Centers for Medicare & Medicaid Services</p> <p><em>Submitted Electronically</em></p> <p><strong>Re: Request for Information; Episode Based Payment Model</strong></p> <p>Dear Administrator Brooks-LaSure,</p> <p>On behalf of our nearly 5,000 member hospitals, health systems and other health care organizations, our clinician partners — including more than 270,000 affiliated physicians, 2 million nurses and other caregivers — and the 43,000 health care leaders who belong to our professional membership groups, the ���������� Association (AHA) appreciates the opportunity to provide feedback on the Episode Based Payment request for information.</p> <p>The AHA applauds the Centers for Medicare & Medicaid Services’ (CMS’) continued efforts to reform reimbursement and develop innovative payment models to incentivize efficiency and improved outcomes. Our members support the U.S. health care system moving toward the provision of more accountable, coordinated care and are continuing to redesign delivery systems to increase value and better serve patients. We believe that episode-based payment models could help further these efforts to transform care delivery through financial accountability and improved care coordination.</p> <p>Over the last 13 years, many of our hospital and health system members have participated in a variety of bundled payment models developed by the Center for Medicare and Medicaid Innovation (CMMI) including Bundled Payments for Care Improvement (BPCI), BPCI Advanced (BPCI-A), and Comprehensive Care for Joint Replacement (CJR). Model design elements like participation criteria, clinical episodes, payment methodologies, metrics and incentives have changed over the course of time. As CMS looks to evolve episode-based payment and develop potential new models, our feedback centers on several core principles:</p> <ul> <li><strong>Transparency</strong>. Models’ methodology, data and design elements should be transparently shared with all potential participants. Proposed changes should be vetted with stakeholders.</li> <li><strong>Flexible Model Design.</strong> Bundled payment model design should be flexible, incorporating features such as voluntary participation, the ability to choose individual clinical episodes, the ability to add components/waivers and options for participants to leave the model(s).</li> <li><strong>Risk Adjustment</strong>. Models should include adequate risk adjustment methodologies and account for social needs. This will ensure they do not inappropriately penalize participants treating the sickest, most complicated and underserved patients. The risk adjustment methodologies should be updated as necessary through the model in coordination with participants and the broader stakeholder community.</li> <li><strong>Resources to Support Initial Investment</strong>. Upfront investment incentives should be provided to support organizations in their transition to episode-based payment. For example, to be successful in such models, hospitals, health systems and provider groups must invest in additional staffing and infrastructure to support care delivery redesign and outcomes tracking. This includes hiring additional staff (like community health workers, care coordinators and analysts) as well as investing in information technology (IT) (software to track outcomes, electronic health record (EHR) interfaces, etc.).</li> <li><strong>Waivers to Address Barriers to Clinical Integration and Care Coordination</strong>. Models should waive the applicable fraud and abuse laws that inhibit care coordination to enable participating hospitals to form the financial relationships necessary to succeed. They should also provide maximum flexibility to identify and place beneficiaries in the clinical setting that best serves their short- and long-term recovery goals. This entails waiving Medicare program regulations that frequently inhibit care coordination and work against participants’ efforts to ensure that care is provided in the right place at the right time</li> <li><strong> Appropriate On Ramp</strong>. Model participants should have an adequate on ramp or glidepath to transition to episode-based payment models. They must have adequate time to implement care delivery changes (integrating new staff, changing clinical workflows, implementing new analytics tools, etc.) and review data prior to initiating the program.</li> <li><strong>Balancing Risk Versus Rewar</strong>d. Models should also balance the risk versus reward in a way that encourages providers to take on additional risk but does not penalize those that need additional time and experience before they are able to do so. A glidepath approach should be implemented, gradually migrating from upside only to downside risk.</li> <li><strong>Establishing Guardrails to Ensure Hospitals Aren’t Competing Against Their Own Best Performanc</strong>e. Models should provide guardrails to ensure that participants do not have to compete against their own best performance and have incentives to remain in models for the long-term.</li> <li><strong>Adequate Model Duration</strong>. Models should be long enough in duration to truly support care delivery transformation and assess impact on outcomes. Episode-based models will take time to demonstrate impact on outcomes. Historically, many have been too short and/or have had multiple, significant design changes even within the designated duration, making it difficult for participants to self-evaluate and change course when necessary.</li> <li><strong>Timely Availability of Data</strong>. Model participants should have readily available, timely access to data about their patient populations. We would encourage dedication of resources from CMS (staff and technology) to provide program participants with more complete data as close to real-time as possible.</li> </ul> <p>Specific feedback on RFI components follows.</p> <h2>CARE DELIVERY AND INCENTIVE STRUCTURE ALIGNMENT</h2> <p>The AHA agrees that incentives must be aligned to support the integration of primary and specialty care, and to support communication, collaboration and coordination across the care continuum. We recognize that bundled payment models must be developed in a manner that encourages care delivery transformation and incentivizes participation from the breadth of providers who touch the patient. As such we recommend the following.</p> <p><strong>Voluntary Participation</strong>. We encourage CMS to ensure that episode-based payment models are voluntary. This means that many organizations may not be of an adequate size or in a financial position to support the investments necessary to transition to mandatory bundled payment models. Requiring them to take on risk for large, diverse bundles of episodes, may require more financial risk than they can bear. This is especially true given the historic financial pressures that hospitals and health systems continue to face. Indeed, according to Kauffman Hall’s June National Hospital Report, while operating margins appear to have stabilized from historic losses, they are still well below historical norms and were under projections.<sup>1</sup></p> <p>Additionally, a Government Accountability Office report found that mandatory participation could negatively impact patient care and financial sustainability if participants are not able to leave the model. It also found that mandatory participation could impact organizations’ ability to support other voluntary models for which they may be better equipped.<sup>2</sup></p> <p>Further, much of the discussion about mandatory participation has been predicated on the high rates of drop out from historical models. However, instead of pursuing mandatory participation, we encourage CMS to address those model design features that led participants to withdraw from historical episode-based payment models in the first place. For example, many decisions to leave were due to index pricing concerns – specifically the ratchet effect where index prices were based on previous years’ performance, thus requiring organizations to compete against their own best performance (see additional information in the payment section).</p> <p><strong>Aligning Incentives to Increase Integration</strong>. Bundled payments can align incentives for providers — hospitals, post-acute care providers, physicians and others — and encourage them to work together to improve the quality and coordination of care. As such, we encourage CMS to provide flexibilities for gainsharing arrangements in future models whereby hospitals could work with physician group practices (PGPs) and post-acute providers to develop mutual accountability and shared risk.</p> <p><strong>Supporting IT Interoperability</strong>. Interoperability between participants and downstream providers is one crucial area that supports care coordination and timely communication. Models should support the entire continuum, from health systems that include downstream episode initiators and practices, to stand-alone hospitals wanting to partner with PGPs to support patients pre- and post-discharge, to other arrangements. Where possible, all organizations caring for the same patient in these models should use the same EHR or have application interfaces that ensure patient information is flowing freely and transparently. This may be challenging in certain scenarios where the participant may need to partner with a provider who lacks the resources to purchase and maintain a sophisticated EHR. As such, CMS should consider expanding Safe Harbor protections (i.e., Stark and Anti-Kickback) for hospitals and health systems to extend access to their EHRs out to others who also fill patient care needs in an episode-based payment model.</p> <p><strong>Regulatory Relief</strong>. AHA continues to call for maximum regulatory relief for all providers participating in alternative payment models. The waiver of certain Medicare program regulations is essential to participants’ ability to coordinate care and ensure that it is provided in the right place at the right time. Participants should have maximum flexibility to identify and place beneficiaries in the clinical setting that best serves their short- and long-term recovery goals. Providing such waivers is also commensurate with the level of risk and accountability that CMS is asking participants to assume as it shifts the burden of risk further away from the Medicare program onto providers. Specifically, we urge CMS to routinely waive:</p> <ul> <li>hospital discharge planning requirements that prohibit hospitals from specifying or otherwise limiting the information provided on post-hospital services;</li> <li>the skilled nursing facility three-day rule;</li> <li>the home health homebound rule;</li> <li>the inpatient rehabilitation facility (IRF) ‘60% Rule;’</li> <li>the IRF ‘Three-hour Rule;’ and</li> <li>the long-term care hospital ‘25% Rule.’</li> </ul> <p>In addition, the application of these and similar fee-for-service regulations in an episode-payment scenario clouds the findings on the efficacy of that model, thereby limiting the potential for lessons learned through the model and its usefulness if, in the future, applied to a broader population of patients and providers.</p> <h2>CLINICAL EPISODES</h2> <p>We generally agree with the considerations CMS outlined for developing clinical episodes for future models, including reviewing clinical homogeneity, spending variability, episode volume, quality impact and episode overlap alignment. We encourage close coordination with the provider community in developing future clinical episodes, to garner feedback on clinical appropriateness, duration and services to be included. Below are specific areas of feedback for clinical episodes.</p> <p><strong>Allow Voluntary Selection of Individual Episodes Instead of Clinical Episode Categories</strong>. It is vitally important for participants to have the ability to select individual clinical episodes, as opposed to requiring participants to take on risk for large, diverse bundles of episodes. This becomes even more important if CMS chooses to pursue any mandatory models.</p> <p>For example, some of the service line groups in BPCI-A included unrelated conditions. The transition to these disparate clinical groups in model year 4 may have contributed to a significant drop of 32% in the number of hospital participants.<sup>3</sup> For example, an organization wanting to participate in the sepsis bundle under BPCI-A was required to support all conditions under “Medical and Clinical Care.” This included conditions such as cellulitis, chronic obstructive pulmonary disease, bronchitis, asthma, renal failure, simple pneumonia, and respiratory infections and urinary tract infections, many of which have no clinical connection to sepsis. This requirement created barriers to participation for organizations that were well positioned to support some but not all episodes within a service line.</p> <p><strong>Focus on MS-DRG Surgical/Medical Episodes</strong>. In general, we encourage CMS to focus bundles on acute surgical and medical episodes and exclude chronic conditions. Acute episodes provide greater opportunities in terms of larger volume, less clinical variability and less model overlap. Chronic conditions may introduce more overlap with other programs like accountable care organizations (ACOs) and likely would require longer durations for episode length and greater complexity in terms of confounding variables.</p> <p><strong>Update Exclusion Criteria</strong>. We encourage CMS to exclude unrelated conditions from bundles. These include but are not limited to pre-scheduled inpatient/outpatient services that occur during the episode’s timeline (e.g., glaucoma surgery), unrelated trauma services and critical care transport. For example, for rural and geographically remote areas, critical care transport often requires high-cost air ambulance services, which may inappropriately and adversely impact these organizations’ cost savings achievements if included. Additionally, we urge CMS to explore revised outlier methodologies to account for patients with unforeseen conditions, such as high-cost trauma or emergent services, or complications from unrelated comorbidities (more feedback on this is in the payment methodology section).</p> <h2>PARTICIPANTS</h2> <p>We encourage CMS to develop the models in a manner that supports transition to risk, including the specific recommendations outlined below.</p> <p><strong>Incentivizing Hospital Participation</strong>. A study of performance of hospitals and physician group practices (PGPs) participating in bundled payment models found that only hospitals achieved cost savings for both surgical and medical episodes.<sup>4</sup> Furthermore, for medical episodes, hospitals demonstrated significant reductions in length of stay at skilled nursing facilities. The study counteracts arguments that PGPs are better suited to provide cost savings in value-based programs. Indeed, hospitals are well positioned to work with post-acute care facilities that may have overlap in patients served and may also be better positioned to assume financial risk. Therefore, it is vitally important that hospitals be fully incentivized to participate in these models.</p> <p><strong>Providing Transparent, Real-time Data</strong>. Historically, the lack of transparent, real-time data has created confusion on trigger events, eligibility for episodes and program participation. We encourage CMS to provide real-time data to conveners and episode initiators.</p> <h2>HEALTH EQUITY</h2> <p>Hospitals and health systems share CMS’ deep commitment to advancing health equity within their organizations and in the communities they serve. We appreciate CMS seeking ways to promote innovative health equity approaches through its CMMI programs. Hospitals approach the critically important work of health equity and addressing health-related social needs (HRSNs) recognizing that while they may be starting from different points, advancing health equity is not just a one-time activity. Rather, it is a continual process that involves engaging with internal and external stakeholders to build understanding and trust, using data to identify where disparities exist, identifying root causes, deploying interventions to address those causes and measuring progress.</p> <p>Below we offer our perspective on several health equity and HRSN-related issues raised in the RFI.</p> <p><strong>Accounting for HRSNs in Payment and Quality</strong>. The AHA supports the concept of CMMI models accounting for the impact of HRSNs in both payment and quality measurement methodologies. Indeed, we believe doing so would complement CMS’ commitment to advancing health equity. Recently, CMS has taken important steps forward in recognizing the complex interplay between provider performance and HRSNs by developing new methodologies to incentivize high quality, efficient care for underserved and historically marginalized communities. For example, the Medicare Shared Savings Program, the Hospital Value-Based Purchasing (VBP) program and Skilled-Nursing Facility VBP program now include a health equity adjustment (HEA) that awards providers bonus points based on a combination of their quality performance and the extent to which they treat underserved patients.</p> <p>We encourage CMS to consider applying approaches like the HEA in its various models. At the same time, CMS should consider the use of a full range of approaches to account for HRSNs in quality measurement and payment — including direct incorporation of HRSN-related variables into risk adjustment models where appropriate. CMMI could, for example, consider using the health equity adjustment’s underserved variables in setting episode-initiator benchmarks, including dual-eligible status (DES), Area Deprivation Index (ADI), and Medicare Part D Low-Income Subsidy. We also encourage CMS to explore the use of the CDC Social Vulnerability Index.</p> <p>The AHA acknowledges that any potential proxy for social risk or health-related social needs has tradeoffs. For example, DES has the significant benefit of being consistently recorded in Medicare administrative data, and relatively easy to tie back to individual hospitals. There also is a body of research showing the link between DES and other measures of social drivers, such as income. At the same time, DES tends to reflect those patients who face the most significant social needs. Furthermore, Medicaid eligibility criteria can vary across states, which means it may be a more comprehensive reflection of underserved populations for some hospitals than for others. Similarly, the main strength of the ADI is that it is attempts to create a multi-dimensional picture of the social drivers of health in a community. It draws on multiple data sources — including Medicare administrative data and census data — and uses 17 indicators of social risk to develop a single score for a geographic region. At the same time, because ADI is calculated at a census-block level, it has the potential to obscure differences within a particular census block. For example, the ADI for a community could look average, but parts of the community may face enormous structural barriers to accessing health care and other supportive resources that lead to better outcomes.</p> <p>Ultimately, CMMI policies around how to account for HRSNs should be informed by careful analysis and, where possible, analyses that estimate their impact on model participants. We encourage the agency to conduct such analyses with as much transparency around methods, data sources and results as possible.</p> <p><strong>Aligning and Sharing Data</strong>. To identify and address health inequities, CMMI model participants need accurate and actionable demographic and HRSN-related data to stratify performance measures and track progress. CMS and CMMI can play a vital role in supporting this work by taking steps to align and share health equity and HRSN-related data with model participants. Specifically, we recommend that CMMI do the following.</p> <ul> <li><strong>Promote aligned and standardized approaches to collecting, analyzing and exchanging demographic and HRSN data</strong>. This includes promoting a consistent approach across CMS itself and other federal agencies and programs. Given the breadth of health equity issues, and the wide range of stakeholders affected by it, CMS can help ensure that all stakeholders use consistent definitions and standards.<br />  </li> <li><strong>Share with model participants existing data to which CMS or other governmental agencies may already have access before adding new data collection and reporting requirements</strong>. For example, to the extent CMS is collecting demographic and social risk data during the time of enrollment in Medicare, the agency should explore ways of improving its accuracy and determine whether the data could be linked to quality measure data for hospitals and other health care providers. These steps could help provide additional data for CMS’ efforts to identify disparities in performance and outcomes, while reducing the need for additional data collection by hospitals and other providers.</li> </ul> <h2>QUALITY MEASURES, INTEROPERABILITY AND MULTI-PAYER ALIGNMENT</h2> <p>The AHA appreciates CMS’ interest in feedback on quality measurement approaches for CMMI models. Given CMMI’s mandate to lower costs while preserving and improving quality, CMMI’s models need well designed quality measures that are accurate, meaningful, feasible to collect and report, and do not require excessive administrative burden. In response to the issues raised in the RFI, AHA offers several recommendations below.</p> <p><strong>Measure Alignment Across Models</strong>. In general, the AHA supports alignment of measures across CMMI models, especially in instances where models are measuring the same topics. Given that many CMMI model participants engage in more than one model, an aligned approach to measurement helps ensure a consistent approach to incentivizing improved performance across programs while also lowering administrative burden for participants. Measure alignment can sometimes be achieved through adopting the same measure across multiple programs, and we encourage CMS to do so when practical. However, even when it is not possible to use identical measures, CMS should work to ensure directional alignment of definitions and methodologies.</p> <p>The AHA also cautions CMS against “force fitting” measures into models simply for the sake of achieving alignment. Sometimes, the differences in the programmatic goals and designs of CMMI models means that using precisely the same measures in each program is not always possible or even desirable. The AHA has previously expressed misgivings about the Merit-based Incentive Program’s APM Payment Pathway (APP) measure set and CMS’ policy of requiring the measure set to be used in every model to qualify for the APP. For example, while the APP measure set includes a depression screening measure, it is not always clear how such screening and follow up are relevant to bundled payment models that focus on procedural inpatient care. As a result, the measure may result in administrative burden that outweighs its value in improving care.</p> <p><strong>Transparency of Measure Specifications</strong>. The AHA urges CMS to increase the transparency of the measure specifications used in various CMMI models. Our members have expressed concern that while they know what measures CMS may be using in particular models, they often do not have enough information about what populations are included in the measure, specific details about risk adjustment methodologies and variables, measurement periods and other details that are vital to understanding how CMMI implements particular measures.</p> <p>Recently, CMS took the step of adding CMMI model measures to its CMS Measure Inventory Tool (CMIT). The AHA appreciates this step and believes there is value in a holistic view of the measures used in CMMI models. However, the information available in the CMIT provides high-level specifications and lacks some of the details described above. We would encourage CMS to build on the information in the CMIT to ensure model participants have the information they need to accurately interpret, implement and track performance on the measures in its models.</p> <p><strong>Use of Patient-reported Outcome Measures (PROMs)</strong>. CMS has expressed interest in the broader use of PROMs in CMMI models and in other CMS programs. In concept, the AHA believes PROMs hold promise in providing meaningful insights into patients’ experience of care and outcomes that matter in their daily lives. For example, many PROMs reflect whether patients are regaining day-to-day physical function within a period after a procedure, such as the ability to walk certain distances without discomfort.</p> <p>However, we urge CMS to adopt a gradual, stepwise approach to implementing PROMs in CMMI models and other programs. This includes making the reporting of PROMs voluntary or rewarding only bonus for successfully undertaking PROM reporting. Experience from the implementation of the total hip arthroplasty/total knee arthroplasty (THA/TKA) PROM in both the CJR model and the Inpatient Quality Reporting (IQR) program has raised significant concerns about the high level of administrative effort and resources needed to collect PROM data. PROM measures usually require at least two patient surveys — one to establish a baseline and a follow up within a set time to measure changes from the baseline. Hospitals have reported that patient follow up is often very challenging, making it difficult to meet CMS’ standards for data completeness. Furthermore, it is not yet clear what a reasonable threshold for data completeness looks like across providers because PROM implementation is still relatively novel on a national scale.</p> <p>In other words, while PROMs have long-term value in CMS programs, both CMS and health care providers need time to develop the infrastructure to support a sustainable implementation of PROM reporting. Voluntary reporting through CMMI models would provide an important opportunity to gain experience, test measurement approaches and share best practices about successful PROM implementation.</p> <p><strong>Multi-Payer Alignment</strong>. The AHA supports multi-payer alignment to ensure consistency across payers in episode composition, payment policies, outcomes metric methodology, and target thresholds. We encourage CMS to work with Medicaid and commercial payers to establish consistent bundled payment models. Aligning payers will also support further transition to value-based care, by bringing all stakeholders to the table and leveraging episodes as a steppingstone or bridge to population-based models.</p> <h2>PAYMENT METHODOLOGY AND STRUCTURE</h2> <p>Some of the biggest challenges in the BPCI, BPCI-A and CJR programs have been related to payment methodology and structure. Below are recommendations to improve payment methodologies for future models.</p> <p><strong>Providing Appropriate Risk Adjustment for Clinical Complexity and Health Related Social Needs.</strong> An article from JAMA analyzing hospitals leaving the CJR program in 2018 found that the majority of those opting out had higher proportions of non-white and Medicaid patients.<sup>5</sup> The article states that these hospitals likely dropped out “since they were more likely to sustain financial losses by remaining in the program” due to higher prevalence of complications and post-acute care needs. This is of deep concern to us. Therefore, we urge CMS to develop models in a manner that incentivizes participation from organizations serving underserved communities. Ensuring adequate risk adjustment methodologies that account for social needs and clinical complexity, as mentioned above, is one policy that would help in this goal.</p> <p><strong>Leveraging Appropriate Breadth of Historical Claims Data for Setting Target Prices</strong>. As part of the extension for the CJR program, CMS updated its methodology for calculating index prices. Specifically, the timeframe for historical claims was adjusted from three years to one year. This continues to be of concern to us. As we previously commented, broader data sets help stabilize target prices and moderate for unforeseen variation, such as in volume or clinical complexity.<sup>6</sup> Therefore, we encourage CMS to use longer time periods in calculating target prices, such as three years.</p> <p><strong>Updating High-cost Spending Caps.</strong> High-cost spending caps are necessary to protect hospitals from incurring undue penalties from unexpected and severe complications. For example, the CJR model originally capped individual episode costs at two standard deviations above the mean. However, CMS later changed the cap to the 99th percentile, which was too high and did not capture the prevalence of severe complications. Therefore, we urge CMS to set high-cost spending caps at two standard deviations above the mean.</p> <p><strong>Create Policies to Help Ensure Organizations Do Not Have To Compete Against Their Own Best Performance</strong>. An article from JAMA identified the issue with the spending benchmark methodology in current episode payment models, whereby participants are essentially penalized for efficiency.<sup>7 </sup>Specifically, benchmarks generally adjust based on historical performance, so if an organization lowers spending, their benchmark will be lowered in future years. As the organization continues to lower spending in an attempt to hit their continually decreasing benchmark, eventually they will not be able to achieve the benchmark. Organizations have cited this as a primary reason for leaving bundled payment programs. CMS has made efforts to enact guardrails to help ensure participants do not have to compete against their own best performance, such as benchmarks that include an adjustment for prior savings and introducing regional trends into benchmarks. “Efficiency floors” are another possibility, which help ensure that organizations are not penalized for reducing spending. In the JAMA article referenced above, an efficiency floor would provide a threshold of spending reductions after which point organizations would not face penalties or could opt out of participation. We strongly encourage CMS to include policies like these in future models, as well as continue researching this issue in general.</p> <p><strong>Stop-loss Limits for Repayments</strong>. We urge CMS to include in models stop-losses that limit participants’ overall repayment responsibility. These should be implemented in a gradual glide-path fashion with additional protections provided for certain participants, such as rural hospitals and lower volume facilities.</p> <p><strong>Incentivizing Post-acute Participation</strong>. Post-acute care (PAC) providers, including long-term care hospitals, inpatient rehabilitation hospitals, skilled nursing facilities and home health agencies, play a key role in ensuring long-term medical and functional outcomes following discharge from an acute-care hospital. Therefore, incentivizing coordination with these providers should be a critical component of models. The intensity of services offered among post-acute care providers can vary greatly, along with the associated cost. However, meaningful differences in outcomes, such as return to daily activities, fall reduction, readmission avoidance and even mortality, and hence savings to Medicare, are not apparent until months or even years later.</p> <p>Utilizing the most efficient downstream provider is the goal, but “efficiency” includes a measure of outcomes achieved, not only cost. As such, models should incorporate measures of functional outcomes to ensure that they are not incentivizing the use of less costly providers without regard to long-term outcomes. We also urge CMS to ensure it provides waivers to enable hospitals’ flexibility to place beneficiaries in the setting that best serves short- and long-term recovery goals. Specifically, we encourage CMS to waive the post-acute care transfer policy when beneficiaries are discharged from an acute care hospital to post-acute facilities and organizations that commit to coordinating with hospital partners for episode- based payment models.</p> <h2>MODEL OVERLAP</h2> <p>As CMS explores ways to better integrate specialty care and ACOs in episode-based payment models, we have several recommendations regarding model overlap, detailed below.</p> <p><strong>Reduce Barriers for Hospitals to Transition to APMs and ACOs</strong>. As CMS evaluates ways to integrate ACOs in episode-based payment models and increase specialty integration, CMS should implement policies to remove barriers to transitioning to risk-based models. For example, CMS should eliminate its designation of ACOs as either low- or high-revenue. The agency has used this label as a proxy measure, for example, to determine if an organization is supporting underserved populations and/or if the organization is physician led in order to qualify for Advance Investment Payments (AIPs). Yet, there is no valid reason to conclude that this delineation, which measures an ACO’s amount of “captured” revenue, is an accurate or appropriate predictor of whether it treats an underserved region. In fact, analysis suggests that critical access hospitals, federally qualified health centers and rural health centers are predominantly classified as “high-revenue,” disqualifying them from obtaining AIPs that would be of a huge benefit in their ability to take on higher risk. Further, both low- and high-revenue ACOs are working to address health equity as part of their care transformation work; assistance investing in these efforts would help across the board. Advanced APM Incentive payments should also be extended to support non-fee-for-service programs, including meal delivery programs, transportation services, and digital tools and care coordinators, each of which promote population health.</p> <p>We appreciate your consideration of these issues. Please contact me if you have questions or feel free to have a member of your team contact Jennifer Holloman, AHA’s senior associate director of policy, at (202) 6262-320 or <a href="mailto:mailto:jholloman@aha.org">jholloman@aha.org</a>.</p> <p>Sincerely,</p> <p>/s/</p> <p>Ashley Thompson<br /> Senior Vice President Policy</p> <p>Cc: Elizabeth Fowler<br />       Director, CMMI</p> Thu, 17 Aug 2023 15:53:55 -0500 Quality Measures /guidesreports/2023-08-03-new-analysis-validates-need-preserve-restrictions-growth-physician-owned-hospitals <div class="container"> <div class="row"> <div class="col-md-8"> <p><strong><span>As some members of Congress continue to propose weakening Medicare’s prohibition on physician self-referral to new </span><a href="/fact-sheets/2023-02-27-fact-sheet-physician-self-referral-physician-owned-hospitals" target="_blank">physician-owned hospitals (POHs)</a><span> and loosening restrictions on the growth of existing POHs, new data from </span><a href="/guidesreports/2023-08-03-analysis-selected-medicare-quality-measure-reporting-data-hospital-ownership">Dobson | DaVanzo</a><span> show that POHs report fewer quality measures and perform worse on readmission penalties compared to full-service community hospitals.</span></strong> Hospital Star Ratings are reported on the Centers for Medicare & Medicaid Services’ (CMS) Care Compare website, and these ratings allow the public to compare hospitals’ performance based on standardized quality metrics.</p> <p>This new analysis reinforces <strong><a href="/news/blog/2023-04-24-physician-owned-hospitals-are-bad-patients-and-communities">previous findings</a></strong> that POHs generally treat a population that is younger, less complex or comorbid, and less likely to be dually eligible for Medicare and Medicaid. Despite treating a healthier and better insured population than similarly situated community hospitals, POHs received higher readmission penalties from CMS. This new study found that:</p> <ul> <li><span><strong>POHs generally report fewer quality measures within each measure domain of Medicare’s Hospital Star Ratings compared to general full-service acute care hospitals.</strong></span> On average, POHs reported fewer measures compared to general acute care hospitals for patient safety (2.8 vs. 5.0 measures), readmissions (4.3 vs. 7.7 measures), and timely and effective care (2.9 vs. 6.4 measures). The fact that POHs report on fewer quality measures demonstrates that they are fundamentally different from full-service community hospitals – they treat fewer patients (and therefore may not reach thresholds for reporting), provide fewer services and do not meet as wide a range of patient clinical needs.</li> <li><span><strong>POHs are more likely to be in the lowest peer group for Hospital Readmissions Reduction Program (HRRP) reporting and perform worse than other hospitals within their own peer group.</strong></span> Peer groups in the HRRP are defined based on the proportion of a hospital’s care that is provided to patients who are dual-eligible for Medicare and Medicaid. Specifically, 78% of POHs were in the lowest dual-eligible peer group for HRRP reporting compared to 19% of general acute care facilities. This finding validates prior research showing that POHs treat far fewer dual-eligible patients than general acute care hospitals.</li> <li><span><strong>POHs performed worse than full-service community hospitals on readmission metrics as part of the HRRP, which reduces Medicare payments to hospitals with excess readmissions.</strong></span> Even though POHs treat younger, less medically complex patients with fewer comorbidities, the report shows that POHs had higher average penalties (0.4% payment reduction vs. 0.3% payment reduction), and a much higher percentage of POHs received the maximum payment penalty compared to general acute care hospitals in the same lowest dual-eligible peer group and market (6.7% vs. 0.5%). At least eight POHs in the lowest peer group received the maximum readmission penalty, which is notable considering only 17 total hospitals (both POH and non-POH) across all five peer groups received the maximum penalty in 2023 and only 10 total hospitals received the maximum penalty in the lowest peer group.<sup><a href="#fn1">1</a></sup></li> </ul> <p>This new analysis adds to more than 15 years of research suggesting that POHs select their patients by avoiding less profitable Medicaid and uninsured patients, treat fewer medically complex patients, and provide fewer emergency services. Beyond validating findings by the Government Accountability Office, <strong><a href="https://oig.hhs.gov/oei/reports/oei-02-06-00310.pdf" target="_blank">Health and Human Services Office of Inspector General</a></strong>, and the <strong><a href="https://www.medpac.gov/wp-content/uploads/import_data/scrape_files/docs/default-source/reports/Mar05_SpecHospitals.pdf" target="_blank">Medicare Payment Advisory Commission</a></strong> that POHs do not treat the same scope, complexity, or acuity of patients as non-POHs within the same market, this analysis also shows that POHs have higher average penalties for readmissions compared to full-service community hospitals. In short, by choosing the healthiest and wealthiest patients, POHs pose program integrity, access and health equity risks for the Medicare program.</p> <p><span><strong>The latest analysis from Dobson | DaVanzo once again reaffirms the need to maintain current law banning physician self-referrals to new POHs and restricting the growth of existing POHs.</strong></span></p> <hr> <ol> <li id="fn1"><a href="https://kffhealthnews.org/news/hospital-penalties/readmissions/" target="_blank">https://kffhealthnews.org/news/hospital-penalties/readmissions/</a></li> </ol> </div> <div class="col-md-4"> <div class="external-link spacer"><a class="btn btn-wide btn-primary" href="/system/files/media/file/2023/08/New-Analysis-Validates-Need-to-Preserve-Restrictions-on-the-Growth-of-Physician-owned-Hospitals.pdf" target="_blank" title="Click here to download the New Analysis Validates Need to Preserve Restrictions on the Growth of Physician-owned Hospitals PDF.">Click here to download the Overview PDF</a></div> <p><a href="/system/files/media/file/2023/08/New-Analysis-Validates-Need-to-Preserve-Restrictions-on-the-Growth-of-Physician-owned-Hospitals.pdf" target="_blank" title="Click here to download the New Analysis Validates Need to Preserve Restrictions on the Growth of Physician-owned Hospitals PDF."><img alt="New Analysis Validates Need to Preserve Restrictions on the Growth of Physician-owned Hospitals page 1." data-entity-type="file" data-entity-uuid="c0138c7a-1726-47bb-ab9e-5f89bc11a1b3" src="/sites/default/files/inline-images/Page-1-New-Analysis-Validates-Need-to-Preserve-Restrictions-on-the-Growth-of-Physician-owned-Hospitals.png" width="691" height="900"></a></p> </div> </div> </div> Thu, 03 Aug 2023 06:15:00 -0500 Quality Measures /guidesreports/2023-08-03-analysis-selected-medicare-quality-measure-reporting-data-hospital-ownership <div class="container"> <div class="row"> <div class="col-md-8"> <h2>Introduction</h2> <p>Dobson | DaVanzo recently examined Medicare claims data comparing demographic and clinical characteristics of facilities and patients receiving care at physician-owned hospitals (POHs) and all other acute care hospitals (non-POHs). That report showed that relative to POHs, non-POHs care for older, more medically complex patients who are on average burdened with multiple co-morbid conditions, while also operating on lower margins and providing more uncompensated and unreimbursed care. Building on this work, we now investigate to what extent differences exist among these hospital groups on their reporting and performance in Medicare’s Hospital Star Rating Domains and Hospital Readmissions Reduction Program (HRRP).<sup><a href="#fn1">1</a></sup> This document outlines the data and methods used and summarizes preliminary findings.</p> <h2>Data and Methods</h2> <p>The POHs represented in this fact sheet were identified based primarily on a June 2016 Physician Hospitals of America list and subsequent FAH/AHA review. Non-POHs are defined as the remaining acute care hospitals that are paid under the inpatient hospital prospective payment system (IPPS) defined under Section 1886(d) of the Social Security Act.<sup><a href="#fn2">2</a></sup> For this analysis, market areas are defined as hospital referral regions (HRRs) from the Dartmouth Atlas of Healthcare, which are made up of zip code area groupings based on the referral patterns of tertiary medical care.<sup><a href="#fn3">3</a></sup> Using data from the January 2023 Hospital General Information file and FY 2023 Hospital Readmissions Reduction Program (HRRP) Supplemental file produced by CMS, we conducted descriptive analyses to compare POHs with non-POHs in POH market areas. POH market areas are defined as any HRR with at least one POH.</p> <h2>Hospital Compare Star Rating Domains Analysis Findings</h2> <p>As shown in Table 1 below, POHs generally reported fewer measures in each of the Hospital Compare Star Rating domains as compared to non-POHs in POH markets. The one exception is the Patient Experience domain, where POHs report a slightly higher average number of measures as compared to non-POHs in POH markets. This further demonstrates that POHs do not treat the same scope, complexity or acuity of patients compared to non-POHs.</p> <hr> <h3>Table 1: Average Count of Measures used in the Overall Hospital Compare Star Rating by Domain, POH vs. Non-POH in POH Markets</h3> <table> <tbody> <tr> <th>Hospital Group</th> <th>Number of Hospitals</th> <th>Average Count of Facility Mortality Measures</th> <th>Average Count of Facility Safety Measures</th> <th>Average Count of Facility Readmission Measures</th> <th>Average Count of Facility Patient Experience Measures</th> <th>Average Count of Facility Timely and Effective Care Measures</th> </tr> <tr> <td>POH</td> <td>158</td> <td>1.3</td> <td>2.8</td> <td>4.3</td> <td>7.1</td> <td>2.9</td> </tr> <tr> <td>Non-POHs in POH Markets</td> <td>1,184</td> <td>4.6</td> <td>5.0</td> <td>7.7</td> <td>7.0</td> <td>6.4</td> </tr> <tr class="bold-faced"> <td>Total</td> <td>1,342</td> <td>4.2</td> <td>4.7</td> <td>7.3</td> <td>7.0</td> <td>6.0</td> </tr> <tr class="bold-faced"> <td>% Difference (POH and Non-POH)</td> <td> </td> <td>111.7%</td> <td>55.4%</td> <td>56.1%</td> <td>2.6%</td> <td>75.4%</td> </tr> </tbody> </table> <p>Notes:</p> <p>Non-acute care hospitals, hospitals that do not participate in in the Inpatient Quality Reporting (IQR) and Outpatient Quality Reporting (OQR) programs (identified via Hospital General Information file footnote 19), and Department of Defense hospitals are excluded.</p> <p>Non-POH hospitals are restricted to those located in the same market as a POH (86 HRRs).</p> <p>The count of facility measures was set to 0 for a facility's domain when the count of measures reported was 'not available' and CMS General information file footnote 5 ('Results are not available for this reporting period') was present.</p> <p>Data shown are rounded to the nearest tenth decimal place. Percent difference is calculated from the unrounded POH and Non-POH average measure count data. Source: Dobson | DaVanzo analysis of 2023 Hospital General Information file produced by CMS.</p> <hr> <h2>Hospital Readmissions Reduction Program (HRRP) Analysis Findings</h2> <p>Hospitals are organized into peer groups in the Hospital Readmissions Reduction Program to measure relative performance on HRRP measures among hospitals that are similarly situated. Congress mandated that CMS implement peer groups in the HRRP beginning on October 1, 2018 in order to account for the influence of health-related social needs on readmissions performance. Peer grouping is designed to facilitate more equitable performance comparisons and payment adjustments across hospitals in the HRRP. These peer groups are defined based on the proportion of a hospital’s care provided to patients who are dually-eligible for Medicare and Medicaid. Dual-eligible proportion is intended to serve as a proxy for the prevalence of health-related social needs among the patients that hospitals serve. Hospitals are peer grouped with other hospitals serving similar proportions of dual-eligible patients and have their readmissions measure performance compared to other hospitals within their peer group.</p> <p>Based on an analysis of FY 2023 HRRP results, the majority of POHs fall into the lowest dual-eligible proportion peer group, which indicates that they treat smaller proportions of dual-eligible patients as compared to non-POHs. Additional detail is shown in Chart 1, below.</p> <h3>Chart 1: Distribution of Hospitals in HRRP Peer Groups in POH Markets</h3> <p><img alt="Distribution of Hospitals in HRRP Peer Groups in POH Markets. HRRP Peer Groups go from lower proportion of dual-eligible patients to higher proportion of dual eligible patients. Group 1: 78% of POHs; 19% of Non-POHs in POH Markets. Group 2: 7% of POHs; 24% of Non-POHs in POH Markets. Group 3: 6% of POHs; 23% of Non-POHs in POH Markets. Group 4: 4% of POHs; 18% of Non-POHs in POH Markets. Group 1: 5% of POHs; 16% of Non-POHs in POH Markets. Source: Dobson | DaVanzo analysis of FY 2023 Hospital Readmissions Reduction Program (HRRP) Supplemental file produced by CMS." data-entity-type="file" data-entity-uuid="8f7ffe68-5706-4918-82d2-13d7cf9a837c" src="/sites/default/files/inline-images/Chart-1-Distribution-of-Hospitals-in-HRRP-Peer-Groups-in-POH-Markets.jpg" width="1181" height="790"></p> <p><small>Source: Dobson | DaVanzo analysis of FY 2023 Hospital Readmissions Reduction Program (HRRP) Supplemental file produced by CMS.</small></p> <p>This finding is consistent with our prior report showing that non-POHs competing with POHs treated 10.7% more dual-eligible patients relative to POHs. In addition, because POHs tend to specialize in selected medical conditions, only 1.3 of the 5 conditions<sup><a href="#fn4">4</a></sup> on average have sufficient volume (25 cases or more) volume to qualify for the HRRP composite measure compared to an average of 3.5 conditions for non-POHs in the Lowest Dual-Eligible Proportion Peer Group. Although the HRRP composite metric consists of only specific conditions that POHs treat, they receive higher Medicare penalties than non-POHs that treat a broader set of conditions and are subjected to more conditions included in the HRRP composite measure. Additional detail is provided in the points and Table 2, below.</p> <ul> <li>119 POHs (78% of all POHs) were in the lowest dual-eligible proportion peer group compared to 216 non-POHs (19% of all non-POHs). Hospitals in this peer group have the lowest proportion of dual-eligible patients.</li> <li>Of the 119 POHs in the lowest dual-eligible proportion peer group, 8 hospitals (6.7%) received the maximum HRRP penalty of 3% in FY2023, compared to only 1 of the 216 non-POHs (0.5%) in the same market.</li> <li>The average HRRP payment reduction percentage for POHs in the lowest dual-eligible proportion peer group was 0.4% compared to non-POHs in the same market of 0.3%.</li> <li>On average only 1.3 of the 5 conditions4 have enough volume to qualify for the HRRP composite measure for POHs in the lowest dual-eligible proportion peer group compared to 3.5 for non-POHs in the same market and dual-eligible proportion peer group.</li> </ul> <hr> <h3>Table 2: Medicare HRRP Penalties and Average Number of Conditions Eligible for HRRP Composite Measure for POHs Compared to Non-POHs in the Lowest Dual-Eligible Proportion Peer Group</h3> <table> <tbody> <tr> <th>Hospital Group</th> <th>Number of Hospitals</th> <th>Average HRRP Payment Reduction Percentage</th> <th>Percent Hospitals with Max HRRP Penalty</th> <th>Average Number of Conditions Eligible for HRRP Composite Measure</th> </tr> <tr> <td>POHs</td> <td>119</td> <td>0.4%</td> <td>6.7%</td> <td>1.3</td> </tr> <tr> <td>Non-POHs in POH Markets</td> <td>216</td> <td>0.3%</td> <td>0.5%</td> <td>3.5</td> </tr> </tbody> </table> <p>Notes:</p> <p>POHs and non-POHs were stratified based on dual-eligibility peer group, which consists of five peer groups based on the hospital’s dual proportion.<sup><a href="#fn5">5</a></sup></p> <p>The HRRP measure is a composite metric that includes hospital excess readmission rates within five conditions/procedures.<sup><a href="#fn6">6</a></sup></p> <p>A hospital must have at least 25 Medicare discharges within condition/procedure for that condition/procedure to be included in the composite metric.</p> <p>Source: Dobson | DaVanzo analysis of FY 2023 Hospital Readmissions Reduction Program (HRRP) Supplemental file produced by CMS.</p> <hr> <h2>Conclusion</h2> <p>As compared to non-POHs in the same market as a POH, POHs appear to report fewer measures in most of the CMS Hospital Compare Star Ratings Domains and are less likely to have adequate volume to qualify for the full breadth of HRRP measures. This suggests POHs are accountable for a narrower scope of quality measure performance than non-POHs. POHs have sometimes asserted that offering more focused services facilitates stronger quality performance. Yet, this analysis shows POHs appear to have slightly higher average readmission penalties. POHs also are disproportionately more likely than similarly situated non-POH hospitals to experience the maximum HRRP penalty. These findings build on our prior work that shows POHs care for a less medically complex Medicare population than non-POHs./p></p> <hr> <ol> <li id="fn1">This study was commissioned by the Federation of ����������s (FAH) and the ���������� Association (AHA).</li> <li id="fn2">Critical Access Hospitals (small rural hospitals), Psychiatric Hospitals, Inpatient Rehabilitation Facilities, Long Term Care Hospitals, and Pediatric Hospitals are excluded.</li> <li id="fn3"><a href="https://www.dartmouthatlas.org/research-methods/" target="_blank">https://www.dartmouthatlas.org/research-methods/</a>.</li> <li id="fn4">4 Note that six measures are typically included in HRRP. However, CMS suppressed one of the measures (pneumonia readmissions) for FY 2023 due to the COVID-19 Public Health Emergency; see <a href="https://qualitynet.cms.gov/inpatient/hrrp/measures" target="_blank">https://qualitynet.cms.gov/inpatient/hrrp/measures</a>.</li> <li id="fn5">Dual proportion is the proportion of Medicare fee-for-service (FFS) and managed care stays in a specific hospital, where the patient was dually eligible for Medi-care and full-benefit Medicaid during the FY 2018 HRRP performance period (July 1, 2013 to June 30, 2016).</li> <li id="fn6">Acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, coronary artery bypass graft, and elective primary total hip and/or knee arthroplasty.</li> </ol> </div> <div class="col-md-4"> <p><a href="/system/files/media/file/2023/08/Analysis-of-Selected-Medicare-Quality-Measure-Reporting-Data-by-Hospital-Ownership.pdf" target="_blank" title="Click here to download the Analysis of Selected Medicare Quality Measure Reporting Data by Hospital Ownership report PDF."><img alt="Analysis of Selected Medicare Quality Measure Reporting Data by Hospital Ownership page 1." data-entity-type="file" data-entity-uuid="ee790405-64bc-4c09-8a66-33987dd21320" src="/sites/default/files/inline-images/Page-1-Analysis-of-Selected-Medicare-Quality-Measure-Reporting-Data-by-Hospital-Ownership.png" width="695" height="900"></a></p> </div> </div> </div> table, th, td { border: 1px solid black; border-collapse: collapse; } tr.bold-faced { font-weight: bold; } th { background-color: #78be2026; } Thu, 03 Aug 2023 06:00:00 -0500 Quality Measures <div class="container"> <div class="row"> <div class="col-md-8"> <p>The Centers for Medicare & Medicaid Services (CMS) July 13 released its calendar year (CY) 2024 outpatient prospective payment system (OPPS) and ambulatory surgical center (ASC) <a href="https://public-inspection.federalregister.gov/2023-14768.pdf" target="_blank">proposed rule</a> that would increase OPPS rates by a net 2.8% in CY 2024 compared to CY 2023. The rule also includes proposals related to hospital price transparency requirements, behavioral health services and Rural Emergency Hospitals (REHs). The final rule will be published on or around Nov. 1 and take effect Jan. 1, 2024. CMS will accept comments on the proposed rule through Sept. 11.</p> <div class="panel module-typeC"> <div class="panel-heading"> <h3>Key Highlights</h3> <p>CMS’ proposed rule would:</p> <ul> <li>Increase Medicare hospital OPPS rates by a net 2.8% in CY 2024 compared to CY 2023.</li> <li>Create standardized formats for hospital price transparency files, including new required data elements such as contracting type for negotiated rates, and establish additional CMS monitoring and enforcement mechanisms.</li> <li>Expand access to behavioral health services, including new coverage for intensive outpatient programs for behavioral health conditions.</li> <li>Pay for 340B acquired drugs and biologicals at the average sales price (ASP) plus 6% and, effective Jan. 1, 2025, require that all 340B hospitals only report the “TB” modifier.</li> <li>Add 10 services to the inpatient-only list.</li> <li>Adopt new measures for the Outpatient, ASC and REH Quality Reporting Programs and modify several others.</li> <li>Seek comments on a potential payment mechanism for hospitals to establish and maintain access to a buffer supply of essential medicines.</li> </ul> </div> </div> <h2>AHA Take</h2> <p>The AHA is deeply concerned that CMS is proposing a CY 2024 outpatient hospital payment update of only 2.8% despite persistent financial headwinds facing the hospital field. Most hospitals across the country continue to operate on negative or very thin margins that make providing care and investing in their workforce very challenging day to day. Without a more robust payment update in the final rule, hospitals’ and health systems’ ability to continue caring for patients and providing essential services for their communities may be jeopardized.</p> <p>Separately, hospitals remain committed to helping patients access the information they need when planning for their care, including meaningful information about the cost of that care. The AHA will be carefully reviewing the proposed changes to the Hospital Price Transparency Rule to ensure they continue to advance our shared objective with CMS of making it easier for patients to access pricing and cost information while reducing unnecessary administrative burden and costs on hospitals and health systems.</p> <h2>What You Can Do</h2> <ul> <li><strong>Participate in an AHA members-only webinar on Friday, Aug. 18 at 2 p.m. ET</strong> to share your questions and feedback on this regulation for AHA’s comment letter to CMS. <a href="https://aha.adobeconnect.com/oppsasc2024/event/registration.html" target="_blank">Register for this 90-minute webinar.</a></li> <li><strong>Share this advisory with your senior management team</strong> and ask your chief financial officer to examine the impact of the proposed payment changes on your Medicare revenue for CY 2024. Spreadsheets comparing the proposed changes in the APC payment rates and weights from 2023 to 2024 are available on the AHA’s <a href="/topics/outpatient-pps">OPPS webpage</a>. To access these, you must be logged on to the website.</li> <li><strong>Share this advisory with your billing, medical records, quality improvement and compliance departments, as well as your clinical leadership team</strong> to apprise them of the proposals around the ambulatory payment classifications (APCs), mental health services, hospital price transparency and quality measurement requirements.</li> <li><strong>Submit comments to CMS with your specific concerns by Sept. 11 at <a href="https://www.regulations.gov/" target="_blank">www.regulations.gov</a>.</strong></li> </ul> <p><strong><em><a href="/system/files/media/file/2023/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2024.pdf" target="_blank" title="Click here to download the Regulatory Advisory: Hospital Outpatient, Ambulatory Surgical Center Proposed Rule for CY 2024 PDF."><span>Download the complete Regulatory Advisory PDF.</span></a></em></strong></p> </div> <div class="col-md-4"> <p><a href="/system/files/media/file/2023/07/Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2024.pdf" target="_blank" title="Click here to download the Regulatory Advisory: Hospital Outpatient, Ambulatory Surgical Center Proposed Rule for CY 2024 PDF."><img alt="Regulatory Advisory: Hospital Outpatient, Ambulatory Surgical Center Proposed Rule for CY 2024 page 1." data-entity-type="file" data-entity-uuid="943f8cf9-0395-44c4-85dd-44c05960648e" src="/sites/default/files/inline-images/Page-1-Regulatory-Advisory-Hospital-Outpatient-Ambulatory-Surgical-Center-Proposed-Rule-for-CY-2024.png" width="695" height="900"></a></p> </div> </div> </div> Fri, 28 Jul 2023 08:05:57 -0500 Quality Measures