Medicare’s Announcement on Monday, July 25, 2016:
New Hip/Femur Fracture Bundles
New Voluntary BPCI-like Bundles Coming in 2018
Guidance on Which Bundles Count as APMs Under MACRA
Hints at Outpatient and Physician-led Episodes of Care in the Future

The health care media focused its attention on the proposal by the Centers for Medicare and Medicaid Services (CMS) on Monday to create mandatory cardiac bundles for AMI and CABG, beginning on July 1, 2017 (similar to the CJR program for TKA/THA in certain markets).

However, CMS also proposed several major changes for orthopaedic surgeons, including:

• The proposed addition of mandatory bundled payments for hip and femur fractures (now known as the Surgical Hip/Femur Fracture Treatment or “SHFFT” model) to the existing CJR (Comprehensive Center for Joint Replacement model) regions, beginning on July 1, 2017.
• Guidance that may allow certain CJR models to count as alternative payment models (APMs) under the new Medicare physician payment program, which is scheduled to begin on January 1, 2017 (but it may be delayed). This is MACRA (Medicare Access and CHIP Reauthorization Act).
• Commentary on the fact that voluntary BPCI (Bundled Payment for Care Improvement) bundles do not meet the requirements for APMs. However, CMS indicated that it plans to introduce new voluntary bundled payments in 2018 that would count as APMs.
• CMS indicated that it may make future bundles to manage episodes of care more centered on physicians and even utilizing the outpatient setting.

The following is TOA’s initial and brief synopsis of Monday’s proposed rule. Keep in mind that much can change for MACRA between now and when the final rule is expected to be released by November 1, 2017. Click here to view CMS’s summary and a link to the 900-plus page proposed rule.

SHFFT Bundles – Focusing on Patients with Chronic Conditions

CMS is proposing to add mandatory hip and femur fracture management bundles to the existing CJR regions, beginning on July 1, 2017.

In its commentary, CMS indicated that lower extremity joint replacements are fairly common among the Medicare population, which serve as the focus of the existing CJR program (TKAs and THAs). CMS went on to indicate that by creating bundles for AMI, CABG, and hip and femur fractures, it is now focusing on a different segment of the Medicare population, which tends to have more chronic conditions. Therefore, the AMI, CABG, and SHFFT bundles are “true episodes of care.”

Mandatory CJR: Will It Now Count as an Advanced APM Under MACRA?

In regards to the three new episodes proposed on Monday (SHFFT, AMI, and CABG), CMS indicated:

Thus, based on the proposed use of these three outcomes measures in the EPMs, we believe the proposed AMI, CABG, and SHFFT models would meet the requirement proposed for Advanced APMs in the Quality Payment Program proposed rule for use of an outcome measure that also meets the general quality requirements (Page 70).

CMS takes a look at CJR (THA and TKA), which began on April 1, 2016, and determines whether it would meet Advanced APM criteria (commentary on page 628):

In this proposed rule, we propose to adopt two different tracks for CJR – Track 1 in which CJR and its participant hospitals would meet the criteria for Advanced APMs as proposed in the Quality Payment Program proposed rule, and Track 2 in which CJR and its participant hospitals would not meet these proposed criteria. The CJR model incorporates a pay-for-performance methodology including quality measures that we believe would meet the proposed Advanced APM quality measure requirements in the Quality Payment Program proposed rule.

The CJR pay-for-performance methodology includes one outcome measure that is NQF-endorsed, has an evidence-based focus, and is reliable and valid. The pay-for-performance methodology incorporates the Hospital-level RSCR following elective primary THA and/or TKA (NQF #1550)(Hip/Knee Complications) outcome measure. Thus, we believe the CJR model would meet the requirement proposed for Advanced APMs in the Quality Payment Program proposed rule for use of an outcome measure that also meets the general quality measure requirements.

Voluntary BPCI: Will It Now Count as an Advanced APM Under MACRA?

CMS provides guidance on BPCI (beginning on page 78). CMS states:

The BPCI initiative Models 2, 3, and 4 would not qualify as Advanced APMs based on the two of the Advanced APM criteria in the Quality Payment Program proposed rule, payment based on quality measures and CEHRT use (81 FR 28298). Specifically, BPCI participants are not currently required to use CEHRT, and although CMS examines the quality of episode care in the BPCI evaluation, BPCI episode payments are not specifically tied to quality performance. Instead, BPCI episode payments are based solely on episode spending performance, although we expect that reductions in spending would generally be linked to improved quality through reductions in hospital readmissions and complications.

Keep in mind that CMS could change its mind when it releases the final MACRA rule (expected around November 1, 2016).

A New Voluntary Bundle That Counts as an Advanced APM for 2018 Is Coming

After providing commentary regarding whether a BPCI model qualifies as an Advanced APM, CMS immediately tells us on page 78 that it plans to create a new voluntary bundled payment model for 2018:

However, building on the BPCI initiative, the Innovation Center intends to implement a new voluntary bundled payment model for CY 2018 where the model(s) would be designed to meet the criteria to be an Advanced APM.

Other Future Event-based Episode Payment Models for Procedures & Medical Conditions

On Page 79, CMS indicates that it intends to create new episode and bundled payments for new procedures and medical conditions. CMS is asking for comment from stakeholders on future payment models.

CMS Doesn’t Forget the Outpatient Setting and “Physician-led Opportunities”

In its commentary seeking feedback on new payment models, CMS indicates that it would like to target procedures that can be performed in both the inpatient and outpatient setting.

CMS also indicates that it would like to incorporate physician leadership into new payment models:

Such models that involve episode payment for procedures furnished in the inpatient or outpatient setting may allow for significant physician-led opportunities that would allow the models to be identified as Advanced APMs.

A Look at Post-acute Providers

CMS provides extensive commentary on the role of post-acute providers in the new payment models and places a particular emphasis on the role of technology. CMS asks for comments regarding the following concepts:

• What are the key challenges associated with the inclusion of post-acute care providers as the financially responsible entity or as collaborators with other financially responsible entities in episode payment models today?
• What would be a sufficient financial incentive or bonus to enhance the adoption, implementation, and upgrading of certified health IT in post-acute care settings?
• How else can episode payment models encourage the use of certified heatlh IT and information sharing among providers and suppliers caring for episode payment model beneficiaries to improve care coordination and patient outcomes?

50% of Physicians Don’t Know What MACRA Is: TOA Is Helping You

A recent study found that 50-percent of physicians do not know what MACRA is. Since TOA has dedicated a lot of effort to educating orthopaedic surgeons about MACRA since Congress began considering the concept in 2014, our hope is that every orthopaedic surgeon in Texas knows what MACRA is.

Lynn Scheps of SRS created a 45-minute webinar for TOA members to utilize. It provides an outstanding overview of MACRA and what orthopaedic surgeons need to know. Click here to access it. Also, TOA is provide 0.75 CME for viewing it (click here to access the quiz to claim CME).

If there is enough interest from the membership, TOA is willing to have an orthopaedic practice consultant travel around Texas to provide an in-person overview of MACRA and guidance. However, we must hear from you if it is of interest.

Virginia orthopaedic surgeon Wilford Gibson, MD shows how Tweeting policymakers, including CMS Administrator Andy Slavitt, can make a difference for medicine. The original MACRA proposed rule that was released in May 2016 did not allow the CJR models to count as Advanced APMs: