/ en Wed, 06 Aug 2025 23:55:15 -0500 Tue, 10 Jun 25 13:34:25 -0500 /2025-06-10-aha-comments-cms-team-payment-model-fy-2026-proposed-inpatient-payment-rule <p>June 10, 2024</p><p>The Honorable Mehmet Oz, M.D.<br>Administrator<br>Centers for Medicare & Medicaid Services<br>Hubert H. Humphrey Building<br>200 Independence Avenue, S.W., Room 445-G<br>Washington, DC 20201</p><p><em>Submitted Electronically</em></p><p><em><strong>RE: CMS-1833-P, Medicare Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2026 Rates; Requirements for Quality Programs; and Other Policy Changes, (Vol. 90, No. 82), April 30, 2025.</strong></em></p><p>Dear Administrator Oz,</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 comment on the Centers for Medicare & Medicaid Services’ (CMS) proposed changes to the Transforming Episode Accountability Model (TEAM). We are submitting separate comments on the agency’s proposed changes to the inpatient and long-term care hospital prospective payment systems (PPSs).</p><p>TEAM is a new, mandatory, episode-based payment model scheduled to begin on Jan. 1, 2026. The five-year program will require acute care hospitals in selected geographic areas to participate in five surgical episodes, including coronary artery bypass graft (CABG), lower extremity joint replacement (LEJR), major bowel procedure, surgical hip/femur fracture treatment (SHFFT) and spinal fusion. TEAM will hold acute care hospitals accountable for the quality and cost of all services provided during select surgical episodes, from the date of inpatient admission or outpatient procedure through 30 days post-discharge. Similar to other bundled payment models, TEAM participants will reconcile performance year spending against a target price to determine if a hospital is eligible for a reconciliation payment or repayment.</p><p>Hospitals and health systems are eager for opportunities to participate in value-based payment arrangements and to drive innovation in the Medicare program. As such, the AHA and its members support innovative payment models that improve quality and lower costs<strong>. However, we continue to be concerned that TEAM does not meet these desired goals and may, in fact, hamper access to care by overburdening providers who do not have the infrastructure or population to be successful in this model, the way it is currently designed.</strong> Indeed, a majority of our <a href="/system/files/media/file/2024/06/aha-comments-on-cms-proposed-transforming-episode-accountability-model-team-letter-6-10-24.pdf">original concerns</a> about the model persist or have even been heightened by this rule. For example, TEAM has a very similar design to models such as Bundled Payments for Care Improvement (BPCI), BPCI Advanced (BPCI-A), and Comprehensive Care for Joint Replacement, none of which have either generated significant net savings or met statutory criteria for expansion, and yet this rule does not change the aspects of TEAM that could result in the same disappointing outcomes. In addition, in four out of the five TEAM episodes, over 71% of costs are incurred during the anchor hospitalization or outpatient procedure, for which reimbursement is already paid on a bundled basis, leaving few opportunities for savings by participants. Furthermore, for procedures such as spinal fusion and LEJR, over 40% of anchor costs are tied to supplies, equipment and implantable devices. We have advocated for exemptions of medical devices and equipment from tariffs, but should they go into effect, hospitals’ and health systems’ ability to impact these costs will decrease even further.<a href="#_ftn1" title="">[1]</a><sup>,</sup><a href="#_ftn2" title=""><sup>[2]</sup></a></p><p><strong>Our primary request continues to be that CMS make TEAM voluntary, as most recently highlighted in our </strong><a href="/system/files/media/file/2025/05/aha-response-to-omb-deregulation-rfi-letter-5-12-2025.pdf"><strong>response</strong></a><strong> to the administration’s deregulation request for information.</strong> Mandatory participation is inappropriate given that many of the selected organizations are neither of an adequate size nor in a financial position to support the investments necessary to transition to mandatory bundled payment models. Requiring hospitals to take on large, diverse bundles would require more risk than many can manage, threatening their ability to maintain access to quality care in their communities.</p><p>View the detailed letter below.</p> Tue, 10 Jun 2025 13:34:25 -0500 Transforming Episode Accountability Model (TEAM) /advisory/2025-05-07-fy-2026-transforming-episode-accountability-model-proposed-rule <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 Transforming Episode Accountability Model (TEAM) /team-webinar-series <div class=""><div class="row"><div class="col-md-12 spacer"><header class="Banner_Title_Overlay_Bar"><img src="/sites/default/files/2024-11/ati-aha-team-webinar-banner-red-blk-1200x300px.jpg" alt="Banner Image" width="1200" height="300"></header></div></div><div class="row"><div class="col-md-10 center_body"><p><br>AHA and ATI Advisory offer a three-part webinar series designed to provide AHA members with a comprehensive overview of the Center for Medicare and Medicaid Innovation’s (CMMI) new mandatory bundled payment model, TEAM (Transforming Episode Accountability Model).</p> .center_body ul li { margin-bottom:10px; } <h2><span>Webinar 1: Understanding the Basics of TEAM</span></h2><p>This webinar covers CMMI’s goals for the model, key components and structure of the model (including timelines and reconciliation details), potential outcomes of the model, and what steps your hospital will need to take to ensure readiness. <span><strong>WATCH REPLAY</strong></span></p><p><span><strong>NOTE:</strong></span> The webinar begins at <strong>0:00:59</strong> of the video.</p></div></div></div> Thu, 31 Oct 2024 07:44:27 -0500 Transforming Episode Accountability Model (TEAM) /advisory/2024-09-16-transforming-episode-accountability-model-team-final-rule <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid (CMS) Aug. 1 <a href="https://www.govinfo.gov/content/pkg/FR-2024-08-28/pdf/2024-17021.pdf" target="_blank" title="New Mandatory Payment Model">finalized</a> a new mandatory payment model that will bundle payment to acute care hospitals for five types of surgical episodes. The Transforming Episode Accountability Model (TEAM), included as part of the fiscal year (FY) 2025 inpatient and long-term care hospital (LTCH) prospective payment system (PPS) final rule, expands upon previous episode-based payment models like the Comprehensive Care for Joint Replacement (CJR) and the Bundled Payments for Care Improvement Advanced (BPCI-A) models. The <a href="/advisory/2024-08-14-inpatient-pps-final-rule-fy-2025" target="_blank">inpatient</a><a href="/advisory/2024-08-14-inpatient-pps-final-rule-fy-2025"> </a>and <a href="/advisory/2024-08-27-long-term-care-hospital-prospective-payment-system-final-rule-fy-2025" target="_blank">LTCH</a> PPS provisions in the final rule are covered in separate <a href="/advisories" target="_blank">AHA advisories.</a> </p><div class="panel module-typeC"><div class="panel-heading"><h2>Key Highlights</h2><p>CMS' Team will: </p><ul><li>Hold acute care hospitals responsible for the quality and costs of all services provided during select surgical episodes, from the date of inpatient admission or outpatient procedure through 30 days post-discharge.</li><li>Require inpatient PPS hospitals to participate in 188 core-based statistical areas (CBSAs).</li><li>Run for five years, from Jan. 1, 2026, through Dec. 31, 2030.</li><li>Include five surgical episode categories: coronary artery bypass graft (CABG), lower extremity joint replacement (LEJR), major bowel procedure, surgical hip/femur fracture treatment (SHFFT) and spinal fusion.</li><li>Provide fee-for-service payments as usual but retrospectively reconcile payments against a target price.</li><li>Provide a one-year glide path to two-sided risk. Safety-net hospitals will have a three-year glide path to downside risk.</li><li>Include stop-loss and stop-gain policies.</li><li>Include waivers for the SNF three-day rule and telehealth originating and geographic sites.</li><li>Link reconciliation payments to quality through performance on hospital-wide all-cause readmissions, CMS patient safety and adverse events composite, and total hip/total knee arthroplasty patient-reported outcome measures.</li><li>Conduct separate rulemaking for policies like low-volume thresholds, hierarchical condition category (HCC) lookback periods, and hospital transfers, which were not finalized in this rule. </li></ul></div></div><h2>AHA TAKE </h2><p>While the AHA has long supported the adoption of value-based and alternative payment models to deliver high-quality care at lower costs, the rule’s mandatory bundled payment model for five different surgical episodes will not advance these objectives. Not only is the model extremely similar to other bundled payment approaches that have failed to meet the statutory criteria for expansion, as they have not reduced program costs or generated net savings, but it also puts at particular risk many hospitals that are not of adequate size or in a position to support the investments necessary to succeed. </p><p>We are particularly disappointed that, despite evidence to suggest that mandatory participation may increase disparities, CMS decided to move forward with its proposal to require certain hospitals to participate in the model. Requiring all hospitals in certain regions to take on large, diverse bundles may require more risk than they can manage, threatening their ability to maintain access to quality care. </p><h2>WHAT YOU CAN DO </h2><ul><li><strong>Watch </strong>for additional materials including additional TEAM proposals from CMS on issues like low-volume thresholds not finalized in this rule.</li><li><strong>Determine </strong>if your organization is included in the list of <a href="https://www.cms.gov/team-model-participant-list" target="_blank">hospitals selected for participation.</a></li><li><strong>Share </strong>this advisory with your chief financial officer, other senior management team members, key physician leaders and nurse managers to examine potential changes for your hospital.</li><li><strong>Assess </strong>the potential impact of the payment and quality changes on your Medicare revenue and operations.</li><li><strong>Register for the AHA member-only </strong><a href="https://aha-org.zoom.us/webinar/register/WN_aWjexSB8SF6GqfmFFx3FPw" target="_blank"><strong>webinar</strong></a><strong> on Sept. 19 at 1 p.m. ET. </strong><em><strong> </strong></em></li></ul><h2>FURTHER QUESTIONS</h2><p>Please direct questions to Jennifer Holloman, AHA’s senior associate director of physician and alternative payment policy, at <a href="mailto:jholloman@aha.org" target="_blank" title="Holloman email"><u>jholloman@aha.org</u></a>. </p></div><div class="col-md-4"><a href="/system/files/media/file/2024/09/transforming-episode-accountability-model-final-rule-advisory-9-16-2024.pdf"><img src="/sites/default/files/inline-images/cover-transforming-episode-accountability-model-final-rule-advisory-9-16-2024.png" data-entity-uuid="d1a17d7b-d718-4eee-9d40-81da2fed8bfd" data-entity-type="file" alt="Regulatory Advisory Image" width="640" height="828"></a></div></div></div> Mon, 16 Sep 2024 10:55:58 -0500 Transforming Episode Accountability Model (TEAM) /lettercomment/2024-06-10-aha-comments-cms-proposed-transforming-episode-accountability-model-team <p>June 10, 2024</p><p>The Honorable Chiquita Brooks-LaSure<br>Administrator<br>Centers for Medicare & Medicaid Services<br>Hubert H. Humphrey Building<br>200 Independence Avenue, S.W., Room 445-G<br>Washington, DC 20201</p><p><em>Submitted Electronically</em></p><p><em><strong>RE: CMS-1808-P, Medicare and Medicaid Programs and the Children’s Health Insurance Program; Hospital Inpatient Prospective Payment Systems for Acute Care Hospitals and the Long-Term Care Hospital Prospective Payment System and Policy Changes and Fiscal Year 2025 Rates; Quality Programs Requirements; and Other Policy Changes, (Vol. 89, No. 86), May 2, 2024.</strong></em></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 proposed Transforming Episode Accountability Model (TEAM). We are submitting separate comments on the agency’s proposed changes to the inpatient and long-term care hospital prospective payment system (PPS).</p><p>We are supportive of the Department of Health and Human Services (HHS) Secretary’s goal of moving toward more accountable, coordinated care through new alternative payment models (APMs). However, we have deep concerns regarding TEAM. CMS is proposing to mandate a model that is has significant design flaws and, as proposed, places too much risk on providers with too little opportunity for reward in the form of shared savings, especially considering the significant upfront investments required<strong>. If CMS cannot make extensive changes to the model, it should not implement it at this time. To do so would make TEAM no more than a backdoor payment cut to hospitals, as it fails to provide hospitals a fair opportunity to achieve enough savings to garner a reconciliation payment.</strong></p><p>Additionally, the programmatic details of TEAM are almost identical to previous iterations of the CMS Innovation Center’s (CMMI) episode-based APMs, including Bundled Payments for Care Improvement Advanced (BPCI-A), and Comprehensive Care for Joint Replacement (CJR). However, we are concerned that the programmatic details of TEAM are almost identical to previous iterations of bundled payment models like CJR and BPCI-A, which, according to CMMI’s own report, have neither generated significant net savings nor met statutory criteria for expansion.<sup>1</sup> In particular, the relevant statute at 42 U.S.C. 1315a(b)(2)(A) directs the agency to “focus on models expected to reduce program costs under the applicable subchapter.” Yet, according to the most recent data from CMS, CJR reported cumulative losses of $142.6 million to the Medicare program in its last year and may have widened disparities in lower extremity joint replacement (LEJR) rates for some populations.<sup>2</sup> BPCI-A generated a net loss of $114 million in its third year, and beneficiaries reported unfavorable results for functional status and care experience measures<strong>.</strong><sup>3</sup> <strong>Thus, because TEAM is based on the extremely similar BPCI-A and CJR models, and because those prior models failed to meet statutory criteria for expansion as they failed to reduce program costs and generate net savings, we have serious concerns that the agency is stretching its legal authority.</strong> Moreover, in not accounting for lessons learned from previous models, we feel the agency has missed a critical opportunity to move bundled payment models forward in a meaningful way.</p><p>Moreover, the tremendous scope of this rule and its aggressive 60-day comment period has made it challenging for us to fully evaluate and analyze the proposal and its tremendous impact on hospitals and health systems. The five types of surgical procedures proposed for inclusion in TEAM comprise over 11% of inpatient PPS payments in 2023 – a staggering amount that does not even include the outpatient payments that would be at risk as part of the model. While we worked closely with our hospital and health system members to assess the potential impact of TEAM on the important work they do in caring for their patients and communities, the incredibly short comment period severely hampers our ability to provide comprehensive comments. That said, it is clear a number of changes need to occur to make this model feasible.</p><h2>Make Participation Voluntary</h2><p>The proposed rule would mandate TEAM participation for all acute care inpatient PPS hospitals in select geographies. However, mandatory participation is not practicable or advisable.<strong> </strong>Many organizations are neither of an adequate size nor in a financial position to support the investments necessary to transition to mandatory bundled payment models. Requiring hospitals to take on large, diverse bundles would require more risk than many can manage, threatening their ability to maintain access to quality care in their communities. <strong>We strongly urge CMS to make model participation voluntary and allow</strong> <strong>organizations to select the episodes for which they feel they can improve quality of care and best impact cost savings.</strong></p><p><u></u></p><h2>Lower the Discount Factor</h2><p>The proposed rule includes a very aggressive 3% discount factor given the context of other TEAM design features.<strong> </strong>Indeed, based on our analysis, each of the five clinical episode categories would have most of the episode spending accounted for by the anchor hospitalization or outpatient procedure, with three of the five having at least three-quarters of spending accounted for by the anchor hospitalization or outpatient procedure. This is extremely problematic as hospitals do not have an ability to decrease the anchor hospitalization payment amount, which leaves virtually no opportunity for them to achieve efficiencies and meet, let alone exceed, the proposed 3% discount factor.<strong> Thus, we recommend that a discount factor of no more than 1% be applied.</strong></p><p><u></u></p><h2>Modify Several Design Elements</h2><p>The proposed rule has several problematic design elements delineated below and explained more thoroughly in the attached<strong>. If CMS cannot make significant changes to our concerns below, the agency should not implement TEAM.</strong> At the very minimum, CMS should:</p><ul><li><u>Revise the risk adjustment factor</u>.<strong> </strong>We recommend that the risk adjustment factor capture complication or comorbidity/major complication or comorbidity (CC/MCC) flags from the anchor hospitalization and hierarchical condition codes (HCC) flags three years prior to the hospitalization.</li><li><u>Establish Longer Glidepath to Two-sided Risk</u>. We recommend extending the upside-only glidepath to a minimum of two years.</li><li><u>Revise the Low-volume Threshold</u>. We recommend CMS increase the low-volume threshold to ensure statistical significance, establish separate thresholds within each episode category and fully exclude organizations not meeting those thresholds from participation.</li><li><u>Make Participation for Safety-net, Rural and Special Designation Hospitals Upside Only. </u>According to our analysis, these organizations are projected to have the most significant financial losses, and they already serve more complex patient populations often with lower margins.</li><li><u>Exclude Hospitals Participating in Other APMs</u>. CMS is creating “double jeopardy” for organizations participating in multiple APMs, and thus should exclude participants in accountable care organizations (ACOs), the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) model, and the Increasing Organ Transplant Accountability model (IOTA). </li><li><u>Revise Quality Measure Set</u>. At the very least, we recommend excluding the three measures CMS is considering for TEAM that have not yet even been adopted for the inpatient PPS quality reporting program.</li><li><u>Lower Composite Quality Score (CQS) Threshold.</u><strong> </strong>Under the proposed approach, model participants would only receive a full reconciliation payment if their CQS is in 100th percentile nationally, essentially meaning that the CQS would serve only to decrease a participant’s reconciliation payment.</li><li><u>Waive Applicable Fraud and Abuse Laws.</u><strong> </strong>We recommend waiving physician self-referral laws and anti-kickback statutes so that organizations can form the financial arrangements necessary to implement the proposed rule.</li><li><u>Extend Certain Waivers to Support Care Delivery</u>. We urge CMS to give providers maximum flexibility to identify and place beneficiaries in the clinical setting that best serves their short- and long-term recovery goals.</li></ul><p>The changes we recommend would help facilitate hospitals’ success in providing quality care to Medicare beneficiaries, achieving savings for the Medicare program and having an opportunity for reward that is commensurate with the risk they are assuming. Our detailed comments are attached. 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 <a href="mailto:jholloman@aha.org">jholloman@aha.org</a>.</p><p>Sincerely,</p><p>/s/</p><p>Ashley Thompson<br>Senior Vice President<br>Public Policy Analysis and Development</p><p>Cc:     Elizabeth Fowler, Director, Center for Medicare and Medicaid Innovation (CMMI)</p><p>_________</p><p><small class="sm"><sup>1</sup> https://www.cms.gov/priorities/innovation/data-and-reports/2022/rtc-2022</small><br><small class="sm"><sup>2</sup> https://www.cms.gov/priorities/innovation/data-<sup>and-reports/2023/cjr-py5-ar-findings-aag</sup></small><br><small class="sm"><sup>3 </sup>https://www.cms.gov/priorities/innovation/data-and-reports/2023/bpci-adv-ar4-findings-aag</small></p> Mon, 10 Jun 2024 10:55:23 -0500 Transforming Episode Accountability Model (TEAM) /action-alert/2024-06-04-use-model-letter-submit-comments-cms-team-proposed-rule <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Innovation (CMMI) April 10 <a href="https://public-inspection.federalregister.gov/2024-07567.pdf">proposed</a> a new mandatory payment model — Transforming Episode Accountability Model (TEAM) — that would bundle payment to acute care hospitals for five types of surgical episodes. The proposed payment model, included as part of the fiscal year 2025 inpatient and long-term care hospital prospective payment system proposed rule, expands upon previous episode-based payment models like the Comprehensive Care for Joint Replacement and the Bundled Payments for Care Improvement Advanced models.</p><p><strong>The AHA has developed a model comment letter that hospitals and health systems can use to assist with submitting to CMS their own comments on the proposed rule. Click </strong><a href="/system/files/media/file/2024/06/Model-Comment-Letter-on-CMS-Transforming-Episode%20Accountability-Model-TEAM-Proposed-Rule.docx"><strong>here</strong></a><strong> to download the model letter.</strong> The letter includes language that urges CMS to not require mandatory participation in TEAM, to lower the proposed discount factor and pursue significant model design changes or not implement the model at all.</p><p>We strongly encourage members to submit their own comments and use the model letter as a guide to share your perspectives. Patient examples, data and other on-the-ground insights your organization can provide about your experience working with bundled payment models, and the impact this mandatory model would have on your patients and hospital will be important as CMS develops final regulations.</p><p>All comments must be submitted before <strong>5 p.m. ET June 10.</strong> You may submit electronic comments at <a href="https://www.regulations.gov">https://www.regulations.gov</a> by following the instructions under the “submit a comment” tab. Please refer to file code “CMS-1808-P” when you submit your letter.</p><p>The AHA will submit its own detailed comment letter, which will be shared with hospitals and health systems once finalized.</p><p><strong>FURTHER QUESTIONS</strong></p><p>If you have further questions, please contact Jennifer Holloman, AHA’s senior director of policy for physician and alternative payment models, at <a href="mailto:jholloman@aha.org">jholloman@aha.org</a>. </p></div><div class="col-md-4"><a href="/system/files/media/file/2024/06/use-model-letter-to-submit-comments-on-cms-team-proposed-rule-alert-6-4-24.pdf" target="_blank"><img src="/sites/default/files/2024-06/cover-use-model-letter-to-submit-comments-on-cms%E2%80%99-team-proposed-rule-alert-6-4-24.png" data-entity-uuid data-entity-type="file" alt=" Cover Action Alert: Use Model Letter to Submit Comments on CMS’ TEAM Proposed Rule" width="NaN" height="NaN"></a></div></div></div> Tue, 04 Jun 2024 14:53:57 -0500 Transforming Episode Accountability Model (TEAM) /advisory/2024-05-01-transforming-episode-accountability-model-team-proposed-rule <div class="container"><div class="row"><div class="col-md-8"><p>The Centers for Medicare & Medicaid Innovation (CMMI) on April 10 <a href="https://public-inspection.federalregister.gov/2024-07567.pdf">proposed</a> a new mandatory payment model that would bundle payment to acute care hospitals for five types of surgical episodes. The proposed payment model, included as part of the FY 2025 inpatient and long-term care hospital (LTCH) prospective payment system (PPS) <a href="https://public-inspection.federalregister.gov/2024-07567.pdf">proposed rule</a>, expands upon previous episode-based payment models like the Comprehensive Care for Joint Replacement (CJR) and the Bundled Payments for Care Improvement Advanced (BPCI-A) models. The <a href="/advisory/2024-04-29-inpatient-pps-proposed-rule-fy-2025">inpatient</a> and <a href="/advisory/2024-04-29-long-term-care-hospital-prospective-payment-system-proposed-rule-fy-2025">LTCH</a> PPS provisions in the proposed rule are covered in separate advisories.</p><h2>KEY HIGHLIGHTS</h2><p>CMMI’s proposed TEAM would:</p><ul><li>Make acute care hospitals responsible for the quality and costs of all services provided during select surgical episodes, from the date of inpatient admission or outpatient procedure through 30-days post-discharge. This includes services covered under both Part A and Part B, including physician, inpatient hospital, inpatient psychiatric facility, LTCH, inpatient rehabilitation facility, skilled-nursing facility (SNF), home health (HH) agency, hospital outpatient, outpatient therapy, clinical laboratory, durable medical equipment, Part B drugs and biologicals (with exceptions) and hospice services.</li><li>Require participation for inpatient PPS hospitals in certain core-based statistical areas (CBSAs) that would be selected at a later date.</li><li>Oversample for participation those CBSAs with high numbers of safety-net hospitals and hospitals that have not previously participated in bundled payment models.</li><li>Run for five years, from Jan. 1, 2026, through Dec. 31, 2030.</li><li>Include five surgical episode categories: coronary artery bypass graft (CABG), lower extremity joint replacement (LEJR), major bowel procedure, surgical hip/femur fracture treatment (SHFFT) and spinal fusion.</li><li>Provide fee-for-service payments as usual but retrospectively reconcile payments against a target price.</li><li>Provide a one-year glidepath to two-sided risk.</li><li>Include stop-loss and stop-gain policies.</li><li>Include waivers for telehealth originating and geographic sites and the SNF three-day rule. CMS intends to address anti-fraud and anti-kickback provisions separately.</li><li>Link reconciliation payments to quality through performance on hospital-wide all-cause readmissions, CMS patient safety and adverse events composite and total hip/total knee arthroplasty patient reported outcome measures.</li><li>Add a new voluntary decarbonization and resilience initiative.</li></ul><h2>AHA TAKE</h2><p>The AHA has long supported adoption of value-based and alternative payment models, especially through demonstration programs that test whether these models support high quality care at lower costs. However, we are concerned that by proposing to mandate participation in this model, the agency has failed to recognize the very real barriers some providers face in building the technical and workforce infrastructure necessary to be successful or the limits posed by an inadequate population base. We are particularly concerned that CMMI is taking a mandatory approach with a bundled payment model that is relatively similar to the current CJR and BPCI-A models since neither of those models have yielded significant net savings.</p><p>We strongly urge CMS to ensure that episode-based payment models are voluntary. Many organizations are not 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 large, diverse bundles may require more risk than they can manage, threatening their ability to maintain access to quality care.</p><h2>WHAT YOU CAN DO</h2><ul><li><strong>Determine, </strong>when available, if your organization is included in one of the CBSAs eligible for selection.</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_COhf4mQmQpuR_GLJNxE9Zg">webinar</a> on May 7 from 12 noon-1 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"><strong>www.regulations.gov</strong></a><strong>. </strong>A final rule on the TEAM could be published as soon as Aug. 1, with a proposed implementation date of Jan. 1, 2026.</li></ul><p>View the detailed Advisory below.</p></div><div class="col-md-4"><a href="/system/files/media/file/2024/05/transforming-episode-accountability-model-proposed-rule-advisory-5-1-24.pdf" target="_blank"><img src="/sites/default/files/2024-05/cover-transforming-episode-accountability-model-proposed-rule-advisory-5-1-24.png" data-entity-uuid data-entity-type="file" alt=" Cover Regulatory Advisory: Transforming Episode Accountability Model (TEAM) Proposed Rule" width="NaN" height="NaN"> </a></div></div></div> Wed, 01 May 2024 10:49:13 -0500 Transforming Episode Accountability Model (TEAM) /issue-brief/2019-01-14-bundled-payments-market-trends-and-markers-success <div class="container row"><div class="row"><div class="col-md-9"><p>Bundled payments have emerged as a reimbursement method that supports health care providers’ efforts to redesign care and improve outcomes for specific patient populations and clinical episodes of care. They offer financial incentives for various providers to work with each other and patients to deliver care in a more coordinated manner.</p><p>The AHA, in collaboration with the University of Pennsylvania’s <a href="https://chibe.upenn.edu/">Center for Health Incentives and Behavioral Economics (CHIBE)</a>, hosted introductory webinars on what bundled payment and episodic care programs are, focusing on relevant research. This summary brief, <a href="/system/files/2019-01/Bundled-Payments_January-2019_final.pdf"><strong>Bundled Payments: Market Trends and Markers of Success</strong></a><strong>,</strong> highlights key takeaways and learnings from this webinar series and discusses key questions, such as how bundled payments affect quality, cost and volume.</p></div><div class="col-md-3 rr_cta">.rr_cta{ border:Solid 1px #69b3e7; padding:1px 15px 11px 15px } .rr_cta li a{ line-height: 1em; margin-bottom: 10px; display: block } .rr_cta li.rr_locked a:after { content: ""; padding: 8px; background: url('/themes/custom/aha/images/icons/type-MembersOnlyContent.svg') white no-repeat; display: inline-block; margin-left: 3px; position: relative; top: 2px; } <div><h4><a href="/center/emerging-issues/market-insights/evolving-care-models">Market Insights: Evolving Care Models</a></h4><ul><li><a href="/center/emerging-issues/market-insights/evolving-care-models/aligning-care-delivery-emerging-payment-models"><strong>Aligning Care Delivery to Emerging Payment Models</strong></a></li><li class="rr_locked"><a href="/center/emerging-issues/market-insights/evolving-care-models/value-snapshot"><strong>Value Snapshot</strong></a></li><li class="rr_locked"><a href="/center/emerging-issues/market-insights/evolving-care-models/23-questions"><strong>23 Questions For Leadership Teams</strong></a></li><li><a href="/center/emerging-issues/market-insights/evolving-care-models/managing-risk-and-new-payment-models"><strong>Managing Risk And New Payment Models</strong></a></li><li><a href="/center/emerging-issues/market-insights/evolving-care-models/hospitals-advancing-accountable-care"><strong>Hospitals Advancing Accountable Care</strong></a></li><li><a href="/center/emerging-issues/market-insights/evolving-care-models/market-trends-bundled-payments"><strong>Market Trends In Bundled Payments</strong></a></li></ul></div></div></div></div> Mon, 14 Jan 2019 13:04:32 -0600 Transforming Episode Accountability Model (TEAM)