Proposed Episode Payment Model for Cardiac Conditions, Fractures Could Impact Labs

The Centers for Medicare & Medicaid Services (CMS) recently released the proposed rule Advancing Care Coordination through Episode Payment Models for three conditions—acute myocardial infarction (AMI), coronary artery bypass graft (CABG), and surgical hip/femur fracture treatment (SHFFT) excluding lower extremity joint replacement.

CMS says the proposed models further its goals of improving both the efficiency and quality of care, particularly for common clinical conditions. Participation will be required by hospitals in certain geographic markets, beginning with a five-year performance evaluation period (July 1, 2017 to Dec. 31, 2021). Each episode for these conditions will extend to within 90 days of hospital discharge. Clinical laboratory services are included in this payment bundle. These three conditions were chosen, in part, because there is known to be significant existing variation in spending for these “high-expenditure, common episodes.”

CMS says it is testing whether an episode payment model for AMI, CABG, and SHFFT care will reduce Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries. It anticipates the proposed models will improve the coordination and transition of care by encouraging provider investment in the redesign of care processes across the inpatient and post-acute care spectrum. The proposed rule includes potential financial risk and rewards for participating hospitals, phased in over time.

For more detailed discussion of this proposed rule, see the September 15, 2016 issue of National Intelligence Report.