Medicare Program; Cancellation of Advancing Care Coordination Through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model (CMS-5524-P), 39310-39333 [2017-17446]
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Federal Register / Vol. 82, No. 158 / Thursday, August 17, 2017 / Proposed Rules
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
42 CFR Parts 510 and 512
[CMS–5524–P]
RIN 0938–AT16
Medicare Program; Cancellation of
Advancing Care Coordination Through
Episode Payment and Cardiac
Rehabilitation Incentive Payment
Models; Changes to Comprehensive
Care for Joint Replacement Payment
Model (CMS–5524–P)
Centers for Medicare &
Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
AGENCY:
This proposed rule proposes
to cancel the Episode Payment Models
(EPMs) and Cardiac Rehabilitation (CR)
incentive payment model and to rescind
the regulations governing these models.
It also proposes to revise certain aspects
of the Comprehensive Care for Joint
Replacement (CJR) model, including:
Giving certain hospitals selected for
participation in the CJR model a onetime option to choose whether to
continue their participation in the
model; technical refinements and
clarifications for certain payment,
reconciliation and quality provisions;
and a change to increase the pool of
eligible clinicians that qualify as
affiliated practitioners under the
Advanced Alternative Payment Model
(APM) track.
DATES: Comment period: To be assured
consideration, comments on this
proposed rule must be received at one
of the addresses provided in the
ADDRESSES section no later than 5 p.m.
EDT on October 16, 2017.
ADDRESSES: In commenting, please refer
to file code CMS–5524–P. Because of
staff and resource limitations, we cannot
accept comments by facsimile (FAX)
transmission.
You may submit comments in one of
four ways (please choose only one of the
ways listed):
1. Electronically. You may submit
electronic comments on this regulation
to https://www.regulations.gov. Follow
the ‘‘Submit a comment’’ instructions.
2. By regular mail. You may mail
written comments to the following
address ONLY: Centers for Medicare &
Medicaid Services, Department of
Health and Human Services, Attention:
CMS–5524–P, P.O. Box 8013, Baltimore,
MD 21244–1850.Please allow sufficient
time for mailed comments to be
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received before the close of the
comment period.
3. By express or overnight mail. You
may send written comments to the
following address ONLY: Centers for
Medicare & Medicaid Services,
Department of Health and Human
Services, Attention: CMS–5524–P, Mail
Stop C4–26–05, 7500 Security
Boulevard, Baltimore, MD 21244–1850.
4. By hand or courier. Alternatively,
you may deliver (by hand or courier)
your written comments ONLY to the
following addresses prior to the close of
the comment period:
a. For delivery in Washington, DC—
Centers for Medicare & Medicaid
Services, Department of Health and
Human Services, Room 445–G, Hubert
H. Humphrey Building, 200
Independence Avenue SW.,
Washington, DC 20201.
(Because access to the interior of the
Hubert H. Humphrey Building is not
readily available to persons without
Federal government identification,
commenters are encouraged to leave
their comments in the CMS drop slots
located in the main lobby of the
building. A stamp-in clock is available
for persons wishing to retain a proof of
filing by stamping in and retaining an
extra copy of the comments being filed.)
b. For delivery in Baltimore, MD—
Centers for Medicare & Medicaid
Services, Department of Health and
Human Services, 7500 Security
Boulevard, Baltimore, MD 21244–1850.
If you intend to deliver your comments
to the Baltimore address, call telephone
number (410) 786–7195 in advance to
schedule your arrival with one of our
staff members.
Comments erroneously mailed to the
addresses indicated as appropriate for
hand or courier delivery may be delayed
and received after the comment period.
For information on viewing public
comments, see the beginning of the
SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT:
For questions related to the CJR
model: CJR@cms.hhs.gov.
For questions related to the EPMs:
EPMRULE@cms.hhs.gov.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All
comments received before the close of
the comment period are available for
viewing by the public, including any
personally identifiable or confidential
business information that is included in
a comment. We post all comments
received before the close of the
comment period on the following Web
site as soon as possible after they have
been received: https://
www.regulations.gov. Follow the search
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instructions on that Web site to view
public comments.
Comments received prior to the
submission deadline will also be
available for public inspection as they
are received, generally beginning
approximately three weeks after
publication of a document, at the
headquarters of the Centers for Medicare
& Medicaid Services, 7500 Security
Boulevard, Baltimore, Maryland 21244,
Monday through Friday of each week
from 8:30 a.m. to 4 p.m. To schedule an
appointment to view public comments,
phone 1–800–743–3951.
Electronic Access
This Federal Register document is
also available from the Federal Register
online database through Federal Digital
System (FDsys), a service of the U.S.
Government Printing Office. This
database can be accessed via the
internet at https://www.gpo.gov/fdsys/.
Acronyms
ACE Acute Care Episode Demonstration
ACO Accountable Care Organization
AMI Acute Myocardial Infarction
APM Alternative Payment Model
BPCI Bundled Payments for Care
Improvement
CABG Coronary Artery Bypass Graft
CCN CMS Certification Number
CCSQ Center for Clinical Standards and
Quality
CEHRT Certified Electronic Health Record
Technology
CEO Chief Executive Officer
CFO Chief Financial Officer
CJR Comprehensive Care for Joint
Replacement
CMS Centers for Medicare & Medicaid
Services
CR Cardiac rehabilitation
CY Calendar Year
E/M Evaluation and Management
EPM Episode payment model
FFS Fee-for-service
FR Federal Register
HACRP Hospital-Acquired Condition
Reduction Program
HHS U.S. Department of Health and Human
Services
HVBP Hospital Value-Based Purchasing
Program
ICD–CM International Classification of
Diseases, Clinical Modification
IFC Interim Final Rule with Comment
Period
IPPS Inpatient Prospective Payment System
LEJR Lower-extremity joint replacement
MPFS Medicare Physician Fee Schedule
MP Malpractice
MSA Metropolitan Statistical Area
MS–DRG Medical Severity DiagnosisRelated Group
NPI National Provider Identifier
NPRA Net Payment Reconciliation Amount
NQF National Quality Forum
OMB Office of Management and Budget
PE Practice Expense
PGP Physician Group Practice
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PRO Patient-Reported Outcome
PY Performance year
QP Qualifying APM Participant
RFA Regulatory Flexibility Act
RSCR Risk-Standardized Complication Rate
RVU Relative Value Unit
SHFFT Surgical hip/femur fracture
treatment
THA Total hip arthroplasty
TIN Taxpayer Identification Number
TKA Total knee arthroplasty
UMRA Unfunded Mandates Reform Act
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I. Executive Summary
A. Purpose
The purpose of this proposed rule is
to propose to cancel the Episode
Payment Models (EPMs) and the
Cardiac Rehabilitation (CR) incentive
payment model, established by the
Center for Medicare and Medicaid
Innovation (Innovation Center) under
the authority of section 1115A of the
Social Security Act (the Act), and to
rescind the regulations at 42 CFR part
512. Additionally, this proposed rule
proposes to prospectively make
participation voluntary for all hospitals
in approximately half of the geographic
areas selected for participation in the
Comprehensive Care for Joint
Replacement (CJR) model (that is, in 33
of the 67 Metropolitan Statistical Areas
(MSAs) selected; (see 80 FR 73299 Table
4)) and for low-volume and rural
hospitals in all of the geographic areas
selected for participation in the CJR
model. We are also proposing several
technical refinements and clarifications
for certain CJR model payment,
reconciliation, and quality provisions,
and a change to the criteria for the
Affiliated Practitioner List to broaden
the CJR Advanced Alternative Payment
Model (APM) track to additional eligible
clinicians.
We note that review and reevaluation
of policies and programs, as well as
revised rulemaking, are within an
agency’s discretion, and that discretion
is often exercised after a change in
administration occurs. The EPMs and
the CR incentive models were designed
as mandatory payment models and
implemented via notice and comment
rulemaking to test the effects of
bundling cardiac and orthopedic care
beginning in 2018 and further
incentivizing higher value care. The CJR
model was also designed as a mandatory
payment model established via notice
and comment rulemaking to test the
effects of bundling on orthopedic
episodes involving lower extremity joint
replacements; we note that the CJR
model began on April 1, 2016 and is
currently in its second performance
year.
While we continue to believe that
cardiac and orthopedic episode models
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offer opportunities to redesign care
processes and improve quality and care
coordination across the inpatient and
post-acute care spectrum while lowering
spending, after careful review, we have
determined that it is appropriate to
propose to rescind the regulations at 42
CFR part 512, which relate to the EPMs
and CR incentive payment model, and
reduce the geographic scope of the CJR
model for the following reasons. First,
we believe that requiring hospitals to
participate in additional episode
payment models at this time is not in
the best interest of the agency or the
affected providers. Many providers are
currently engaged in voluntary
initiatives with CMS, and we expect to
continue to offer opportunities for
providers to participate in voluntary
initiatives, including episode-based
payment models. We are concerned that
engaging in large mandatory episode
payment model efforts at this time may
impede our ability to engage providers,
such as hospitals, in future voluntary
efforts. Similarly, we also believe that
reducing the number of providers
required to participate in the CJR model
will allow us to continue to evaluate the
effects of such a model while limiting
the geographic reach of our current
mandatory models. We considered
altering the design of the EPMs and the
CR incentive payment model to allow
for voluntary participation and to take
into account other feedback on the
models, but as this would potentially
involve restructuring the model design,
payment methodologies, financial
arrangement provisions and/or quality
measures, we did not believe that such
alterations would offer providers
enough time to prepare for such
changes, given the planned January 1,
2018 start date. In addition, if at a later
date we decide to test these models, or
similar models, on a voluntary basis, we
would not expect to implement them
through rulemaking, but rather would
use methods of soliciting applications
and securing participants’ agreement to
participate consistent with how we have
implemented other voluntary models.
Finally, we believe that canceling the
EPMs and CR incentive payment model,
as well as altering the scope of the CJR
model, offers CMS greater flexibility to
design and test other episode-based
payment models, while still allowing us
to test and evaluate the impact of the
ongoing CJR model on enhancing the
quality of care while reducing costs.
Hospitals in the CJR model have been
participating for more than a year and
a half, and we have begun to give
hospitals in the model financial and
quality results from the first
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performance year. In many cases, CJR
hospitals have made investments in care
redesign, and we want to recognize such
investments and commitments to
improvement while reducing the overall
number of hospitals that are required to
participate.
We seek public comment on the
proposals contained in this proposed
rule, and also on any alternatives
considered.
B. Summary of Economic Effects
We do not anticipate that our
proposal to cancel the EPMs and CR
incentive payment model prior to the
start of those models will have any costs
to providers. As shown in our impact
analysis in section V. of this proposed
rule, we estimate that the CJR model
changes we are proposing will reduce
the previously projected CJR model
savings (82 FR 603) by approximately
$90 million. Therefore, we estimate that
the total CJR model impact after the
changes in this proposed rule will save
the Medicare program $204 million,
instead of $294 million, over the
remaining 3-year performance period
(2018 through 2020) of the CJR model.
Our impact analysis has some degree of
uncertainty and makes assumptions as
discussed in section V. of this proposed
rule. In addition to these estimated
impacts, as with many of the Innovation
Center models, the goals that
participants are attempting to achieve
include improving overall quality of
care, enhancing participating provider
infrastructure to support better care
management and reducing costs. We
anticipate there will continue to be a
broader focus on care coordination and
quality improvement through the CJR
model among hospitals and other
providers and suppliers within the
Medicare program that may lead to
better care management and improved
quality of care for beneficiaries.
II. Statutory Authority and Background
Under the authority of section 1115A
of the Social Security Act (the Act),
through notice-and-comment
rulemaking, CMS’ Center for Medicare
and Medicaid Innovation (Innovation
Center) established the Comprehensive
Care for Joint Replacement model in a
final rule titled ‘‘Medicare Program;
Comprehensive Care for Joint
Replacement Payment Model for Acute
Care Hospitals Furnishing Lower
Extremity Joint Replacement Services’’
published in the November 24, 2015
Federal Register (80 FR 73274 through
73554) (referred to in this proposed rule
as the ‘‘CJR model final rule’’). We
established three new models for acute
myocardial infarction, coronary artery
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bypass graft, and surgical hip/femur
fracture treatment episodes of care,
which are collectively called the
Episode Payment Models (EPMs),
created a Cardiac Rehabilitation
incentive payment model (CR incentive
payment model), and revised several
existing provisions for the CJR model, in
a final rule titled ‘‘Advancing Care
Coordination Through Episode Payment
Models (EPMs); Cardiac Rehabilitation
Incentive Payment Model; and Changes
to the Comprehensive Care for Joint
Replacement Model’’ published in the
January 3, 2017 Federal Register (82 FR
180) (referred to in this proposed rule as
the ‘‘EPM final rule’’).
The effective date for most of the
provisions of the EPM final rule was
February 18, 2017, and in the EPM final
rule we specified an effective date of
July 1, 2017 for certain CJR model
regulatory changes intended to align
with a July 1, 2017 applicability, or
start, date for the EPMs and CR
incentive payment model. On January
20, 2017, the Assistant to the President
and Chief of Staff issued a
memorandum titled ‘‘Regulatory Freeze
Pending Review’’ that instructed
Federal agencies to temporarily
postpone the effective date for 60 days
from the date of the memorandum for
regulations that had been published in
the Federal Register but had not taken
effect, for purposes of reviewing the
rules and considering potentially
proposing further notice-and-comment
rulemaking. Accordingly, on February
17, 2017, we issued a final rule in the
Federal Register (82 FR 10961) to delay
until March 21, 2017 the effective date
of any provisions of the EPM final rule
that were to become effective on
February 18, 2017. We subsequently
issued an interim final rule with
comment (IFC) period in the Federal
Register on March 21, 2017 (referred to
in this proposed rule as the ‘‘March 21,
2017 IFC’’) (82 FR 14464). The March
21, 2017 IFC further delayed the
effective date of the provisions that were
to take effect March 21, 2017 until May
20, 2017, further delayed the
applicability date of the EPMs and CR
incentive payment model provisions
until October 1, 2017, and further
delayed the effective date of the
conforming CJR model changes until
October 1, 2017. In the March 21, 2017
IFC, we also solicited public comment
on further delaying the applicability
date for the EPMs and CR incentive
payment provisions, as well as the
effective date for the conforming
changes to the CJR model from October
1, 2017 until January 1, 2018 to allow
for additional notice-and-comment
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rulemaking. Based on the public
comments we received in response to
the March 21, 2017 IFC, we published
a final rule (referred to in this proposed
rule as the ‘‘May 19, 2017 final delay
rule’’) on May 19, 2017 (82 FR 22895)
to finalize a January 1, 2018
applicability date for the EPMs and CR
incentive payment provisions, as well as
to finalize a January 1, 2018 effective
date for the conforming changes to the
CJR model (specifically amending
§ 510.2; adding § 510.110; amending
§ 510.120; amending § 510.405;
amending § 510.410; revising § 510.500;
revising § 510.505; adding § 510.506;
and amending § 510.515). Additional
changes to the CJR model, in accordance
with the March 21, 2017 IFC, took effect
May 20, 2017.
As we stated in the May 19, 2017 final
delay rule (82 FR 22897), we received a
number of comments on the models that
did not relate to the start date change
comment solicitation. These additional
comments suggested that we reconsider
or revise various model aspects, policies
and design components; in particular,
many of these comments suggested that
we should make participation in the
models voluntary instead of mandatory.
We did not respond to these comments
in the May 19, 2017 final delay rule, as
the comments were out of scope of that
rulemaking, but we stated that we might
take them into consideration in future
rulemaking.
Our specific proposals are discussed
in the following sections of this
proposed rule.
III. Provisions of the Proposed
Regulations
A. Proposed Cancellation of EPMs and
Cardiac Rehabilitation Incentive
Payment Model
In the January 3, 2017 EPM final rule,
we established three bundled payment
models for acute myocardial infarction
(AMI), coronary artery bypass graft
(CABG), and surgical hip/femur fracture
treatment (SHFFT) episodes, and a
Cardiac Rehabilitation (CR) incentive
payment model. These models are
similar to other Innovation Center
models and focus on more complex
cases where we believe improvements
in care coordination and other care
redesign efforts offer the potential for
improved patient outcomes and more
efficient use of resources. Many
stakeholders, including commenters
responding to the March 21, 2017 IFC,
have expressed concerns about the
provider burden and challenges these
new models present. As we noted in the
May 19, 2017 final delay rule (82 FR
22896), which finalized a January 1,
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2018 start date for the EPMs and the CR
incentive payment model, we would
engage in notice and comment
rulemaking on these models if we
believed it to be warranted. We also
noted that we received 47 submissions
in response to the March 21, 2017 IFC.
These responses contained a mix of inand out-of-scope comments (82 FR
22899). In the May 19, 2017 final delay
rule (82 FR 22897), we noted that in
addition to commenting on the change
to the effective date for the EPMs and
CR incentive payment model and
certain provisions of the CJR model,
commenters highlighted concerns with
the models’ design, including but not
limited to participation requirements,
data, pricing, quality measures, episode
length, CR and skilled nursing facility
(SNF) waivers, beneficiary exclusions
and notification requirements,
repayment, coding, and model overlap
issues. Specifically, many commenters
were opposed to the mandatory
participation requirements, arguing that
the mandatory nature of these models
would force many providers who lack
familiarity, experience, or proper
infrastructure to quickly support care
redesign efforts for a new bundled
payment system. Many commenters
were concerned that the mandatory
nature of these models might harm
patients and providers before CMS
knows how these models might affect
access to care, quality or outcomes in
various locations. Additionally,
commenters were concerned that
unrelated services would be
incorporated into episode prices under
the finalized price setting methodology,
which bases prices on MS–DRGs and
identifies excluded, unrelated services
rather than included, related services
based on clinical review. Commenters
also expressed concern that this pricing
approach would result in diagnosis
codes that would be classified as
included services, when in fact these
services have no clinical relevance to
the episode(s). Commenters were further
concerned with the fact that CMS will
progressively incorporate regional data
into EPM target prices, where 100
percent of the EPM target price would
be based on regional data by
performance year 4. Commenters also
took issue with the quality measures
established for the SHFFT model,
stating that these measures are not
clinically related to the target
population and are inappropriate for use
in assessing the care provided to
beneficiaries in the SHFFT model. In
addition, commenters requested
revisions to the CABG EPM to allow
participants the option to use a CABG
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composite score developed by the
Society of Thoracic Surgeons (STS)
rather than the all-cause mortality
measure.
Commenters also expressed concerns
about the design of the CR incentive
payment model waivers. Commenters
stated that current direct supervision
requirements would continue to
contribute to a lack of access to cardiac
rehabilitation services and would
inhibit providers’ ability to redesign
care for the CR incentive payment
model. Commenters suggested
broadening the CR physician
supervision waiver because the current
waivers would not cover non-model
beneficiaries who might be obtaining
services concurrently with model
participants and are therefore not
sufficient. Other commenters were
concerned with the precedence rules for
model overlap with Models 2, 3 and 4
of the Innovation Center’s Bundled
Payments for Care Improvement (BPCI)
initiative.
In the May 19, 2017 final delay rule
(82 FR 22895), we stated that we might
consider these public comments in
future rulemaking. Based on our
additional review and consideration of
this stakeholder feedback, we have
concluded that certain aspects of the
design of the EPMs and the CR incentive
payment model should be improved and
more fully developed prior to the start
of the models, and that moving forward
with the implementation of the EPMs
and CR incentive payment model as put
forth in the January 3, 2017 EPM final
rule would not be in the best interest of
beneficiaries or providers at this time.
Based on our acknowledgment of the
many concerns about the design of these
models articulated by stakeholders, we
are proposing to cancel the EPMs and
CR incentive payment model before
they begin. Accordingly, we propose to
rescind 42 CFR part 512 in its entirety.
We seek public comment on our
proposal to cancel the EPMs and CR
incentive payment model.
We note that, if the proposal to cancel
the EPMs and CR incentive payment
model is finalized, providers interested
in participating in bundled payment
models may still have an opportunity to
do so during calendar year (CY) 2018
via new voluntary bundled payment
models. Building on the BPCI initiative,
the Innovation Center expects to
develop new voluntary bundled
payment model(s) during CY 2018 that
would be designed to meet the criteria
to be an Advanced APM. We also note
the strong evidence base and other
positive stakeholder feedback that we
have received regarding the CR
incentive payment model. As we further
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develop the Innovation Center’s
portfolio of models, we may revisit this
model and will consider stakeholder
feedback for a potential new voluntary
initiative.
B. Proposed Changes to the CJR Model
Participation Requirements
1. Proposed Voluntary Participation
Election (Opt-In) for Certain MSAs and
Low-Volume and Rural Hospitals
The CJR model began on April 1,
2016. The CJR model is currently in the
second performance year, which
includes episodes ending on or after
January 1, 2017 and on or before
December 31, 2017. The third
performance year, which includes all
CJR episodes ending on or after January
1, 2018 and on or before December 31,
2018, would necessarily incorporate
episodes beginning before January 2018.
The fifth, and last, performance year
would end on December 31, 2020.
Currently, with limited exceptions,
hospitals located in the 67 geographic
areas selected for participation in the
CJR model must participate in the
model through December 31, 2020; that
is, their participation in the CJR model
is mandatory unless the hospital is an
episode initiator for a lower-extremity
joint replacement (LEJR) episode in the
risk-bearing period of Models 2 or 4 of
the BPCI initiative. Hospitals with a
CCN primary address in the 67 selected
geographic areas that participated in
Model 1 of the BPCI initiative, which
ended on December 31, 2016, began
participating in the CJR model when
their participation in the BPCI initiative
ended.
Based on smaller, voluntary tests of
episode-based payment models and
demonstrations, such as the Acute Care
Episode (ACE) demonstration and the
BPCI initiative, that have indicated a
potential to improve beneficiaries’ care
while reducing costs (see ACE
evaluation at: https://
downloads.cms.gov/files/cmmi/aceevaluationreport-final-5-2-14.pdf and
BPCI evaluation at: https://
innovation.cms.gov/Files/reports/BPCIEvalRpt1.pdf), we finalized the CJR
model with mandatory participation in
the 67 selected geographic areas so that
we could further test delivery of better
care at a lower cost across a wide range
of hospitals, including some hospitals
that may not otherwise participate, in
many locations across the country. In
the CJR model final rule (80 FR 73276),
we stated that we believed that by
requiring the participation of a large
number of hospitals with diverse
characteristics, the CJR model would
result in a robust data set for evaluation
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of this bundled payment approach, and
would stimulate the rapid development
of new evidence-based knowledge.
Testing the model in this manner would
also allow us to learn more about
patterns of inefficient utilization of
health care services and how to
incentivize the improvement of quality
for common LEJR procedure episodes.
After further consideration of
stakeholder feedback, including
responses we received on the March 21,
2017 IFC, we are proposing certain
revisions to the mandatory participation
requirements for the CJR model to allow
us to continue to evaluate the effects of
the model while limiting the geographic
reach of our current mandatory models.
Specifically, we are proposing that the
CJR model would continue on a
mandatory basis in approximately half
of the selected geographic areas (that is,
34 of the 67 selected geographic areas),
with an exception for low-volume and
rural hospitals, and continue on a
voluntary basis in the other areas (that
is, 33 of the 67 selected geographic
areas).
The geographic areas for the CJR
model are certain Metropolitan
Statistical Areas (MSAs) that were
selected following the requirements in
§ 510.105 as discussed in the CJR model
final rule (80 FR 73297 through 73299).
In § 510.2, an MSA is defined as a corebased statistical area associated with at
least one urbanized area that has a
population of at least 50,000. In
selecting the 67 MSAs for inclusion in
the CJR model, the 196 eligible MSAs
were stratified into 8 groups based on
MSA average wage adjusted historic
LEJR episode payments and MSA
population size (80 FR 41207).
Specifically, we classified MSAs
according to their average LEJR episode
payment into four categories based on
the 25th, 50th and 75th percentiles of
the distribution of the 196 potentially
selectable MSAs as determined in the
exclusion rules as applied in the CJR
model proposed rule (80 FR 41198).
This approach ranked the MSAs relative
to one another and created four equally
sized groups of 49. The population
distribution was divided at the median
point for the MSAs eligible for potential
selection, creating 8 groups. Of the 196
eligible MSAs, we chose 67 MSAs via a
stratified random selection process as
discussed in the CJR model final rule
(80 FR 73291). In reviewing our
discussion of the MSA selection and the
MSA volume needed to provide
adequate statistical power to evaluate
the impact of the model in the CJR
model final rule (80 FR 73297), we have
determined that reducing the mandatory
MSA volume in half by selecting the 34
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MSAs with the highest average wageadjusted historic LEJR episode
payments for continued mandatory
participation could still allow us to
evaluate the effects of the CJR model
across a wide range of providers,
including some that might not otherwise
participate in the model. Higher
payment areas are most likely to have
significant room for improvement in
creating efficiencies and greater
variations in practice patterns. Thus, the
selection of more expensive MSAs is the
most appropriate approach to fulfilling
the overall priorities of the CJR model
to increase efficiencies and savings for
LEJR episodes while maintaining or
improving the overall quality of care.
The original determination of the
sample size need in the CJR model final
rule was constructed to be able to
observe a 2-percent reduction in wageadjusted episode spending after 1 year.
This amount was chosen based on the
anticipated amount of the discount
applied in the target price. In
considering the degree of certainty that
would be needed to generate reliable
statistical estimates, we assumed a 20
percent chance of false positive and a 30
percent chance of a false negative. Using
these parameters, we determined that
the number of MSAs needed ranged
from 50 to 150. In order to allow for
some degree of flexibility, we selected
75 MSAs, which were narrowed to 67
due to final exclusion criteria.
As we reviewed the CJR model for
this proposed rule, we noted that,
excluding quarterly reconciliation
amounts, evaluation results from BPCI
Model 2 have indicated possible
reductions in fee-for-service spending of
approximately 3 percent on orthopedic
surgery episodes for hospitals
participating in the LEJR episode
bundle. (https://innovation.cms.gov/
Files/reports/bpci-models2-4yr2evalrpt.pdf). We examined the
sample size needed to detect a 3-percent
reduction in CJR model episode
spending after 1 year using the same
methodology as described in the CJR
model final rule. We determined that we
would be able to meet this standard
with 34 MSAs from the higher cost
groups. We expect that hospitals in the
higher cost MSAs will be able to achieve
similar 3 percent savings given their
MSA’s relatively high historic episode
spending and thus greater opportunities
for improvements, and their experience
in optimizing clinical care pathways to
produce greater efficacies over the first
two performance years of the CJR
model. We note that the proposed
changes to the model, including the
focus on higher cost MSAs and the
reduced number of mandatory MSAs,
VerDate Sep<11>2014
19:57 Aug 16, 2017
Jkt 241001
will cause changes to the nature of the
evaluation.
To select the 34 MSAs that would
continue to have mandatory
participation (except for low-volume
and rural hospitals), we took the
distribution of average wage-adjusted
historic LEJR episode payments for the
67 MSAs using the definition described
in the CJR model final rule, ordered
them sequentially by average wageadjusted historic LEJR episode
payments, and then selected the 34
MSAs with the highest average
payments. Under this proposal to
reduce the number of MSAs with
mandatory participation, the remaining
33 MSAs would no longer be subject to
the CJR model’s mandatory
participation requirements; that is,
hospital participation would be
voluntary in these 33 MSAs.
After dividing the 67 MSAs into 34
mandatory and 33 voluntary MSAs as
described previously, we examined
selected MSA characteristics. In order to
determine whether a good balance was
maintained across MSA population size,
we examined the number of MSAs
below and above the median population
point of the 196 MSAs eligible for
potential selection. We observed that a
good balance of MSA population size
was maintained (17 out of 34 mandatory
and 17 out of 33 voluntary MSAs had
a population above the median
population). While the 34 MSAs that
would continue to have mandatory
participation have higher spending on
average, these MSAs all include
providers with average cost episodes in
addition to providers with high cost
episodes. In general, we note that
hospitals located in higher cost areas
have a greater potential to demonstrate
significant decreases in episode
spending. However, within the higher
cost MSAs, there is still significant
variation in characteristics and
experiences of the included hospitals.
We anticipate the evaluation will be
able to assess the generalizability of the
findings of the CJR model by examining
variations of performance within the
participating hospitals who represent a
wide range of hospital and market
characteristics. Therefore, we are
proposing that the CJR model would
have 34 mandatory participation MSAs
(identified in Table 1) and 33 voluntary
participation MSAs (identified in Table
2) for performance years 3, 4, and 5.
Specifically, we are proposing that,
unless an exclusion in § 510.100(b)
applies (that is, for certain hospitals that
participate in the BPCI initiative),
participant hospitals in the proposed 34
mandatory participation MSAs that are
not low-volume or rural (as defined in
PO 00000
Frm 00006
Fmt 4701
Sfmt 4702
§ 510.2 and discussed in the following
paragraphs) would continue to be
required to participate in the CJR model.
We are also proposing that hospitals in
the proposed 33 voluntary participation
MSAs and hospitals that are lowvolume or rural (as defined in § 510.2
and discussed in the following
paragraphs) would have a one-time
opportunity to notify CMS, in the form
and manner specified by CMS, of their
election to continue their participation
in the CJR model on a voluntary basis
(opt-in) for performance years 3, 4, and
5. Hospitals that choose to participate in
the CJR model and make a participation
election that complies with proposed
§ 510.115 would be subject to all model
requirements. Hospitals in the proposed
33 voluntary participation MSAs and
low-volume and rural hospitals (as
defined in § 510.2 and discussed in the
following paragraphs) that do not make
a participation election would be
withdrawn from the CJR model as
described later in this section of this
proposed rule.
We are proposing to exclude and
automatically withdraw low-volume
hospitals in the proposed 34 mandatory
participation MSAs, as identified by
CMS (see Table 3), from participation in
the CJR model effective February 1,
2018. Since some low-volume hospitals
may want to continue their participation
in the CJR model, we are proposing to
allow low-volume hospitals to make a
one-time, voluntary participation
election that complies with the
proposed § 510.115 in order for the lowvolume hospital to continues its
participation in the CJR model. We are
proposing to define a low-volume
hospital in § 510.2 as a hospital
identified by CMS as having fewer than
20 LEJR episodes in total across the 3
historical years of data used to calculate
the performance year 1 CJR episode
target prices. Note that under this
definition, all hospitals listed in Table
3 would meet the definition of a lowvolume hospital, but this list would not
be inclusive of all hospitals that could
be identified by CMS as a low-volume
hospital. For example, a new hospital
(with a new CCN) that opens in a
mandatory MSA during the remaining
years of the CJR model would not have
any LEJR episodes during the historical
years of data used to calculate the
performance year 1 CJR episode target
prices. Under our proposal, we intend
that any hospital with a new CCN that
comes into existence after the proposed
voluntary participation election period
would not be required and/or eligible to
join the CJR model. Note that our
proposed policy for new hospitals
E:\FR\FM\17AUP2.SGM
17AUP2
Federal Register / Vol. 82, No. 158 / Thursday, August 17, 2017 / Proposed Rules
would not be applicable in the case of
a reorganization event where the
remaining entity is a hospital with a
CCN that was participating in the CJR
model prior to the reorganization event;
consistent with our current policy, such
hospital would continue participation
in the CJR model regardless of whether
all predecessor hospitals were
participant hospitals prior to the
reorganization event.
We are also proposing to exclude and
automatically withdraw rural hospitals
from participation in the CJR model
effective February 1, 2018. Since some
rural hospitals may want to continue
their participation in the CJR model, we
are proposing to allow rural hospitals to
make a one-time, voluntary
participation election that complies
with the proposed § 510.115 in order for
the rural hospital to continues its
participation in the CJR model.
Specifically, we are proposing that rural
hospitals (as defined in § 510.2) with a
CCN primary address in the 34
mandatory participation MSAs would
have a one-time opportunity to opt-in to
continue its participation in the CJR
model during the proposed voluntary
participation election period. We are
proposing that a hospital’s change in
rural status after the end of the
voluntary participation election period
would not change the hospital’s CJR
model participation requirements.
Specifically, we are proposing that
hospitals in the proposed 34 mandatory
participation MSAs that are neither lowvolume or rural hospitals during the
proposed voluntary participation
election period would be required to
participate in the CJR model for
performance years 3, 4, and 5, and that
39315
these hospitals would continue to be
required to participate in the CJR model
even if they subsequently become a
rural hospital. Similarly, we are
proposing that a rural hospital that
makes a voluntary participation election
during the one-time opportunity would
be required to continue participating in
the CJR model if that hospital no longer
meets the definition of rural hospital in
§ 510.2. We are proposing this approach
so that CMS can identify the hospitals,
by CCN, that would participate in the
model for the remainder of performance
year 3 and performance years 4 and 5
at the conclusion of the proposed
voluntary participation election period
and so that there would be less
confusion about which hospitals are CJR
model participants. We seek comment
on this proposal.
TABLE 1—CJR MANDATORY PARTICIPATION MSAS
MSA
sradovich on DSK3GMQ082PROD with PROPOSALS2
10420
11700
12420
13140
17140
18580
20020
22500
23540
24780
25420
26300
28660
31080
31180
32820
33100
33740
33860
35300
35380
35620
36420
36740
37860
38300
38940
39340
39740
42680
45300
45780
46220
46340
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
Wage-adjusted
episode
payments
(in $)
MSA name
Akron, OH ................................................................................................................................................................
Asheville, NC ...........................................................................................................................................................
Austin-Round Rock, TX ...........................................................................................................................................
Beaumont-Port Arthur, TX .......................................................................................................................................
Cincinnati, OH-KY-IN ..............................................................................................................................................
Corpus Christi, TX ...................................................................................................................................................
Dothan, AL ..............................................................................................................................................................
Florence, SC ...........................................................................................................................................................
Gainesville, FL .........................................................................................................................................................
Greenville, NC .........................................................................................................................................................
Harrisburg-Carlisle, PA ............................................................................................................................................
Hot Springs, AR ......................................................................................................................................................
Killeen-Temple, TX ..................................................................................................................................................
Los Angeles-Long Beach-Anaheim, CA .................................................................................................................
Lubbock, TX ............................................................................................................................................................
Memphis, TN-MS-AR ..............................................................................................................................................
Miami-Fort Lauderdale-West Palm Beach, FL ........................................................................................................
Monroe, LA ..............................................................................................................................................................
Montgomery, AL ......................................................................................................................................................
New Haven-Milford, CT ...........................................................................................................................................
New Orleans-Metairie, LA .......................................................................................................................................
New York-Newark-Jersey City, NY-NJ-PA .............................................................................................................
Oklahoma City, OK .................................................................................................................................................
Orlando-Kissimmee-Sanford, FL .............................................................................................................................
Pensacola-Ferry Pass-Brent, FL .............................................................................................................................
Pittsburgh, PA .........................................................................................................................................................
Port St. Lucie, FL ....................................................................................................................................................
Provo-Orem, UT ......................................................................................................................................................
Reading, PA ............................................................................................................................................................
Sebastian-Vero Beach, FL ......................................................................................................................................
Tampa-St. Petersburg-Clearwater, FL ....................................................................................................................
Toledo, OH ..............................................................................................................................................................
Tuscaloosa, AL ........................................................................................................................................................
Tyler, TX ..................................................................................................................................................................
$28,081
27,617
28,960
32,544
28,074
30,700
30,710
27,901
29,370
27,446
28,360
29,621
27,355
28,219
29,524
28,916
33,072
30,431
30,817
27,529
29,562
31,076
27,267
29,259
29,485
30,886
30,423
28,852
28,679
28,015
32,424
28,658
31,789
30,955
TABLE 2—CJR VOLUNTARY PARTICIPATION MSAS
Wage-adjusted
episode
payments
(in $)
MSA
MSA name
10740 .............
12020 .............
Albuquerque, NM ....................................................................................................................................................
Athens-Clarke County, GA ......................................................................................................................................
VerDate Sep<11>2014
21:01 Aug 16, 2017
Jkt 241001
PO 00000
Frm 00007
Fmt 4701
Sfmt 4702
E:\FR\FM\17AUP2.SGM
17AUP2
$25,892
25,394
39316
Federal Register / Vol. 82, No. 158 / Thursday, August 17, 2017 / Proposed Rules
TABLE 2—CJR VOLUNTARY PARTICIPATION MSAS—Continued
MSA
13900
14500
15380
16020
16180
16740
17860
19500
19740
20500
22420
23580
26900
28140
30700
31540
33340
33700
34940
34980
35980
36260
38900
40980
41180
41860
42660
43780
44420
45820
48620
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
.............
Wage-adjusted
episode
payments
(in $)
MSA name
Bismarck, ND ..........................................................................................................................................................
Boulder, CO .............................................................................................................................................................
Buffalo-Cheektowaga-Niagara Falls, NY ................................................................................................................
Cape Girardeau, MO-IL ...........................................................................................................................................
Carson City, NV ......................................................................................................................................................
Charlotte-Concord-Gastonia, NC-SC ......................................................................................................................
Columbia, MO .........................................................................................................................................................
Decatur, IL ...............................................................................................................................................................
Denver-Aurora-Lakewood, CO ................................................................................................................................
Durham-Chapel Hill, NC ..........................................................................................................................................
Flint, MI ....................................................................................................................................................................
Gainesville, GA ........................................................................................................................................................
Indianapolis-Carmel-Anderson, IN ..........................................................................................................................
Kansas City, MO-KS ...............................................................................................................................................
Lincoln, NE ..............................................................................................................................................................
Madison, WI ............................................................................................................................................................
Milwaukee-Waukesha-West Allis, WI ......................................................................................................................
Modesto, CA ............................................................................................................................................................
Naples-Immokalee-Marco Island, FL ......................................................................................................................
Nashville-Davidson-Murfreesboro-Franklin, TN ......................................................................................................
Norwich-New London, CT .......................................................................................................................................
Ogden-Clearfield, UT ..............................................................................................................................................
Portland-Vancouver-Hillsboro, OR-WA ...................................................................................................................
Saginaw, MI .............................................................................................................................................................
St. Louis, MO-IL ......................................................................................................................................................
San Francisco-Oakland-Hayward, CA ....................................................................................................................
Seattle-Tacoma-Bellevue, WA ................................................................................................................................
South Bend-Mishawaka, IN-MI ...............................................................................................................................
Staunton-Waynesboro, VA ......................................................................................................................................
Topeka, KS ..............................................................................................................................................................
Wichita, KS ..............................................................................................................................................................
22,479
24,115
26,037
24,564
26,128
26,736
25,558
24,846
26,119
25,151
24,807
23,009
25,841
27,261
27,173
24,442
25,698
24,819
27,120
26,880
25,780
25,472
22,604
25,488
26,425
23,716
23,669
23,143
25,539
24,273
25,945
TABLE 3—LOW-VOLUME HOSPITALS LOCATED IN THE MANDATORY MSAS ELIGIBLE TO OPT-IN DURING VOLUNTARY
ELECTION PERIOD
sradovich on DSK3GMQ082PROD with PROPOSALS2
CCN
010034
010062
010095
010097
010108
010109
010149
040132
050040
050091
050137
050138
050139
050158
050205
050373
050378
050411
050468
050543
050548
050552
050561
050609
050641
050677
050723
050738
050744
050747
050751
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
VerDate Sep<11>2014
Hospital name
MSA
Community Hospital, Inc .........................................................
Wiregrass Medical Center ......................................................
Hale County Hospital ..............................................................
Elmore Community Hospital ...................................................
Prattville Baptist Hospital ........................................................
Pickens County Medical Center .............................................
Baptist Medical Center East ...................................................
Leo N. Levi National Arthritis Hospital ....................................
LAC-Olive View-UCLA Medical Center ..................................
Community Hospital of Huntington Park ................................
Kaiser Foundation Hospital-Panorama City ...........................
Kaiser Foundation Hospital-Los Angeles ...............................
Kaiser Foundation Hospital-Downey ......................................
Encino Hospital Medical Center .............................................
Glendora Community Hospital ................................................
LAC+USC Medical Center ......................................................
Pacifica Hospital of the Valley ................................................
Kaiser Foundation Hospital-South Bay ...................................
Memorial Hospital of Gardena ................................................
College Hospital Costa Mesa .................................................
Fairview Developmental Center ..............................................
Motion Picture & Television Hospital ......................................
Kaiser Foundation Hospital-West Los Angeles ......................
Kaiser Foundation Hospital-Orange County-Anaheim ...........
East Los Angeles Doctors Hospital ........................................
Kaiser Foundation Hospital-Woodland Hills ...........................
Kaiser Foundation Hospital-Baldwin Park ..............................
Greater El Monte Community Hospital ...................................
Anaheim Global Medical Center .............................................
South Coast Global Medical Center .......................................
Miracle Mile Medical Center ...................................................
19:57 Aug 16, 2017
Jkt 241001
PO 00000
Frm 00008
Fmt 4701
Sfmt 4702
33860
20020
46220
33860
33860
46220
33860
26300
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
31080
MSA Title
Montgomery, AL.
Dothan, AL.
Tuscaloosa, AL.
Montgomery, AL.
Montgomery, AL.
Tuscaloosa, AL.
Montgomery, AL.
Hot Springs, AR.
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
Los Angeles-Long
E:\FR\FM\17AUP2.SGM
17AUP2
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
Beach-Anaheim,
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
CA.
Federal Register / Vol. 82, No. 158 / Thursday, August 17, 2017 / Proposed Rules
39317
TABLE 3—LOW-VOLUME HOSPITALS LOCATED IN THE MANDATORY MSAS ELIGIBLE TO OPT-IN DURING VOLUNTARY
ELECTION PERIOD—Continued
CCN
sradovich on DSK3GMQ082PROD with PROPOSALS2
050771
050776
050779
050780
050782
070038
070039
100048
100130
100240
100277
100320
100326
190005
190011
190079
190245
190300
190302
190308
190313
250012
250126
250167
310058
330080
330086
330100
330199
330231
330233
330240
330385
330396
330397
330399
330405
360241
370011
370158
370199
370206
370215
370234
390184
390217
420057
420066
440131
450143
450605
450690
450865
460043
670087
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
...........
Hospital name
Coast Plaza Hospital ..............................................................
College Medical Center ..........................................................
Martin Luther King Jr. Community Hospital ............................
Foothill Medical Center ...........................................................
Casa Colina Hospital ..............................................................
Connecticut Hospice Inc .........................................................
Masonic Home and Hospital ...................................................
Jay Hospital ............................................................................
Lakeside Medical Center ........................................................
Anne Bates Leach Eye Hospital .............................................
Douglas Gardens Hospital ......................................................
Poinciana Medical Center .......................................................
Promise Hospital of Miami ......................................................
University Medical Center New Orleans .................................
University Health Conway .......................................................
St. Charles Parish Hospital .....................................................
Monroe Surgical Hospital ........................................................
St. Charles Surgical Hospital LLC ..........................................
Omega Hospital LLC ..............................................................
St. Bernard Parish Hospital ....................................................
New Orleans East Hospital .....................................................
Alliance Healthcare System ....................................................
North Oak Regional Medical Center .......................................
Methodist Olive Branch Hospital ............................................
Bergen Regional Medical Center ............................................
Lincoln Medical & Mental Health Center ................................
Montefiore Mount Vernon Hospital .........................................
New York Eye and Ear Infirmary ............................................
Metropolitan Hospital Center ..................................................
Queens Hospital Center .........................................................
Brookdale Hospital Medical Center ........................................
Harlem Hospital Center ..........................................................
North Central Bronx Hospital ..................................................
Woodhull Medical and Mental Health Center .........................
Interfaith Medical Center .........................................................
St. Barnabas Hospital .............................................................
Helen Hayes Hospital .............................................................
Edwin Shaw Rehab Institute ...................................................
Mercy Hospital El Reno Inc. ...................................................
Purcell Municipal Hospital .......................................................
Lakeside Women’s Hospital A Member of INTEGRIS Health
Oklahoma Spine Hospital .......................................................
Oklahoma Heart Hospital ........................................................
Oklahoma Heart Hospital South .............................................
Highlands Hospital ..................................................................
Excela Health Frick Hospital ...................................................
McLeod Medical Center-Darlington ........................................
Lake City Community Hospital ...............................................
Baptist Memorial Hospital Tipton ............................................
Seton Smithville Regional Hospital .........................................
Care Regional Medical Center ...............................................
University of Texas Health Science Center at Tyler ..............
Seton Southwest Hospital .......................................................
Orem Community Hospital ......................................................
Baylor Scott & White Emergency Medical Center-Cedar
Park.
As stated previously in this section,
we are proposing a one-time
participation election period for
hospitals with a CCN primary address
located in the voluntary participation
MSAs listed in Table 2, low-volume
hospitals specified in Table 3, and rural
hospitals in the mandatory participation
MSAs. Based on the anticipated timing
for when the final rule implementing
VerDate Sep<11>2014
MSA
19:57 Aug 16, 2017
Jkt 241001
31080
31080
31080
31080
31080
35300
35300
37860
33100
33100
33100
36740
33100
35380
33740
35380
33740
35380
35380
35380
35380
32820
32820
32820
35620
35620
35620
35620
35620
35620
35620
35620
35620
35620
35620
35620
35620
10420
36420
36420
36420
36420
36420
36420
38300
38300
22500
22500
32820
12420
18580
46340
12420
39340
12420
this proposal would be published, we
propose that the voluntary participation
election period would begin January 1,
2018, and would end January 31, 2018.
We must receive the participation
election letter no later than January 31,
2018. We are proposing that the
hospital’s participation election letter
would serve as the model participant
agreement. Voluntary participation
PO 00000
Frm 00009
Fmt 4701
Sfmt 4702
MSA Title
Los Angeles-Long Beach-Anaheim, CA.
Los Angeles-Long Beach-Anaheim, CA.
Los Angeles-Long Beach-Anaheim, CA.
Los Angeles-Long Beach-Anaheim, CA.
Los Angeles-Long Beach-Anaheim, CA.
New Haven-Milford, CT.
New Haven-Milford, CT.
Pensacola-Ferry Pass-Brent, FL.
Miami-Fort Lauderdale-West Palm Beach, FL.
Miami-Fort Lauderdale-West Palm Beach, FL.
Miami-Fort Lauderdale-West Palm Beach, FL.
Orlando-Kissimmee-Sanford, FL.
Miami-Fort Lauderdale-West Palm Beach, FL.
New Orleans-Metairie, LA.
Monroe, LA.
New Orleans-Metairie, LA.
Monroe, LA.
New Orleans-Metairie, LA.
New Orleans-Metairie, LA.
New Orleans-Metairie, LA.
New Orleans-Metairie, LA.
Memphis, TN-MS-AR.
Memphis, TN-MS-AR.
Memphis, TN-MS-AR.
New York-Newark-Jersey City, NY-NJ-PA.
New York-Newark-Jersey City, NY-NJ-PA.
New York-Newark-Jersey City, NY-NJ-PA.
New York-Newark-Jersey City, NY-NJ-PA.
New York-Newark-Jersey City, NY-NJ-PA.
New York-Newark-Jersey City, NY-NJ-PA.
New York-Newark-Jersey City, NY-NJ-PA.
New York-Newark-Jersey City, NY-NJ-PA.
New York-Newark-Jersey City, NY-NJ-PA.
New York-Newark-Jersey City, NY-NJ-PA.
New York-Newark-Jersey City, NY-NJ-PA.
New York-Newark-Jersey City, NY-NJ-PA.
New York-Newark-Jersey City, NY-NJ-PA.
Akron, OH.
Oklahoma City, OK.
Oklahoma City, OK.
Oklahoma City, OK.
Oklahoma City, OK.
Oklahoma City, OK.
Oklahoma City, OK.
Pittsburgh, PA.
Pittsburgh, PA.
Florence, SC.
Florence, SC.
Memphis, TN-MS-AR.
Austin-Round Rock, TX.
Corpus Christi, TX.
Tyler, TX.
Austin-Round Rock, TX.
Provo-Orem, UT.
Austin-Round Rock, TX.
would begin February 1, 2018, and
continue through the end of the CJR
model, unless sooner terminated. Thus,
participant hospitals located in the
voluntary participation MSAs listed in
Table 2, the low-volume hospitals
specified in Table 3, and the rural
hospitals in the 34 mandatory
participation MSAs that elect voluntary
participation would continue in the CJR
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model without any disruption to
episodes attributed to performance year
3, which begins January 1, 2018.
Participant hospitals located in the
voluntary participation MSAs listed in
Table 2, the low-volume hospitals
specified in Table 3, and the rural
hospitals in the 34 mandatory
participation MSAs that do not elect
voluntary participation would be
withdrawn from the model effective
February 1, 2018, and all of their
performance year 3 episodes up to and
including that date would be canceled,
so that these hospitals would not be
subject to a reconciliation payment or
repayment amount for performance year
3. We are proposing to implement our
proposed opt-in approach in this
manner as a way to balance several
goals, including establishing a uniform
time period for hospitals to make a
voluntary participation election,
avoiding disruption of episodes for
hospitals that elect to continue their
participation in the CJR model, and
preventing confusion about whether a
hospital is participating in performance
year 3 of the model. Specifically, we
considered whether adopting a
voluntary election period that ended
prior to the start of performance year 3
would be less confusing and less
administratively burdensome in terms
of whether a hospital is participating in
performance year 3. To implement this
approach, the voluntary participation
election period would have to close by
December 31, 2017, such that each
hospital would have made its
determination regarding participation in
performance year 3 before the start of
performance year 3 (note that episodes
attributed to performance year 3 would
still be canceled under this alternative
approach for eligible hospitals that do
not make a participation election).
Because the voluntary election period
under this approach would conclude in
advance of the relevant CJR model
performance year, this approach could
simplify our administration of
performance year 3 by establishing in
advance of performance year 3 whether
a hospital would be a participant
hospital for the totality of performance
year 3. However, given the timing of this
proposed rulemaking, we were not
confident that hospitals would have
sufficient time to make a voluntary
participation election by December 31,
2017. Thus, we are proposing that the
voluntary participation election period
would occur during the first month of
performance year 3 (that is, throughout
January 2018) and would apply
prospectively beginning on February 1,
2018. We believe this approach will best
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ensure adequate time for hospitals to
make a participation election while
minimizing the time period during
which participation in performance year
3 remains mandatory for all eligible
hospitals in the 67 selected MSAs. We
note that based on timing
considerations, including potential
changes to the anticipated date of
publication of the final rule, we may
modify the dates of the voluntary
participation election period and make
conforming changes to the dates for
voluntary participation in performance
year 3. We seek comment on the
proposed voluntary participation
election period, including whether we
should instead require the participation
election to be made by December 31,
2017 (that is, prior to the start of
performance year 3) or if a different or
later voluntary election period may be
preferable.
To specify their participation election,
we are proposing that hospitals would
submit a written participation election
letter to CMS in a form and manner
specified by CMS. We intend to provide
templates that can easily be completed
and submitted in order to limit the
burden on hospitals seeking to opt-in. If
a hospital with a CCN primary address
located in the voluntary participation
MSAs or a low-volume or rural hospital
in the mandatory participation MSAs
does not submit a written participation
election letter by January 31, 2018, the
hospital’s participation in performance
year 3 would end, all of its performance
year 3 episodes would be canceled, and
it would not be included in the CJR
model for performance years 4 and 5.
We are proposing a number of
requirements for the participation
election letter and that the hospital’s
participation election letter would serve
as the model participant agreement.
First, we are proposing that the
participation election letter must
include all of the following:
• Hospital Name.
• Hospital Address.
• Hospital CCN.
• Hospital contact name, telephone
number, and email address.
• If selecting the Advanced APM
track, attestation of CEHRT use as
defined in § 414.1305.
Second, we are proposing that the
participation election letter must
include a certification in a form and
manner specific by CMS that—
• The hospital will comply with all
requirements of the CJR model (that is,
42 CFR 510) and all other laws and
regulations that are applicable to its
participation in the CJR model; and
• Any data or information submitted
to CMS will be accurate, complete and
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truthful, including, but not limited to,
the participation election letter and any
quality data or other information that
CMS uses in reconciliation processes or
payment calculations or both.
We solicit feedback on this proposed
certification requirement, including
whether the certification should include
different or additional attestations.
Finally, we are proposing that the
participation election letter be signed by
the hospital administrator, chief
financial officer (CFO) or chief
executive officer (CEO).
We are proposing that, if the
hospital’s participation election letter
meets these criteria, we would accept
the hospital’s participation election.
Once a participation election for the CJR
model is made and is effective, the
participant hospital would be required
to participate in all activities related to
the CJR model for the remainder of the
CJR model unless the hospital’s
participation is terminated sooner.
We note that episodes end 90 days
after discharge for the CJR model and
episodes that do not start and end in the
same calendar year will be attributed to
the following performance year. For
example, episodes that start in October
2017 and do not end on or before
December 31, 2017 are attributed to
performance year 3. Our methodology
for attributing these episodes to the
subsequent performance year would be
problematic in cases where a hospital
with a CCN primary address located in
a voluntary participation MSA or a rural
hospital or a low-volume hospital, as
specified by CMS, has not elected to
voluntarily continue participating in the
model. Therefore, for a hospital with a
CCN primary address located in a
voluntary participation MSA, or a rural
hospital or a low-volume hospital, as
specified by CMS, that does not elect
voluntary participation during the onetime voluntary participation election
period, we are proposing that all
episodes attributed to performance year
3 for that hospital would be canceled
and would not be included in payment
reconciliation. Such hospitals would
have their participation in the CJR
model withdrawn effective February 1,
2018. We note that this proposal is
consistent with our policy for treatment
of episodes that have not ended by or
on the last day of performance year 5
and cannot be included in performance
year 5 reconciliation due to the end of
the model (see Table 8 of the CJR model
final rule (80 FR 73326)).
We are proposing to define a lowvolume hospital, mandatory MSA, and
voluntary MSA, to change the definition
of participant hospital in § 510.2, and to
amend the specification of the
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geographic areas in § 510.105(a) to
reflect the establishment of mandatory
and voluntary participation MSAs. We
are proposing to codify the opt-in
proposal in new § 510.115. In addition,
we are proposing to post the list of
mandatory participation MSAs,
voluntary participation MSAs, and lowvolume hospitals on the CJR model Web
site.
We believe our proposed opt-in
approach to allow for voluntary
participation in the CJR model by
certain hospitals would be less
burdensome on such hospitals than a
potential alternative approach of
requiring hospitals to opt-out of the
model. In developing the proposal to
allow eligible hospitals located in the
proposed 33 voluntary participation
MSAs and low-volume and rural
hospitals located in the 34 mandatory
participation MSAs to elect voluntary
participation, we considered whether to
propose that hospitals would have to
make an affirmative voluntary
participation election (that is, an opt-in
approach) or to propose that these
hospitals would continue to be required
to participate in the CJR model unless
written notification was given to CMS to
withdraw the hospital from the CJR
model (that is, an opt-out approach). We
believe an opt-in approach would be
less burdensome on hospitals, because it
would not require participation in the
CJR model for hospitals located in the
proposed 33 voluntary participation
MSAs and for low-volume and rural
hospitals located in the 34 mandatory
participation MSAs unless the hospital
affirmatively chose it. Further, we
believe requiring an affirmative opt-in
election would result in less ambiguity
about a hospital’s participation
intentions as compared to an opt-out
approach. Specifically, with an opt-in
approach, a hospital’s participation
election would document each
hospital’s choice, whereas under an optout approach there could be instances
where hospitals fail to timely notify
CMS of their desire to withdraw from
participation and are thus included in
the model and subject to potential
repayment amounts. For these reasons,
we have proposed an opt-in approach.
We seek comment on this proposal and
the alternative considered.
We also believe that our proposed
approach to make the CJR model
primarily concentrated in the higher
cost MSAs where the opportunity for
further efficiencies and care redesign
may be more likely and allow voluntary
participation in the lower cost MSAs
and for low-volume and rural hospitals
allows the Innovation Center to focus on
areas where the opportunity for further
efficiencies and care redesign may be
more likely, while still allowing
hospitals in the voluntary MSAs the
opportunity to participate in the model.
In developing this proposed rule, we
considered that hospitals in the CJR
model have been participating for over
a year and a half as of the timing of this
proposed rule, and we have begun to
give hospitals in the model financial
and quality results from the first
performance year. In many cases,
participant hospitals have made
investments in care redesign, and we
want to recognize such investments and
commitments to improvement while
reducing the overall number of hospitals
that are required to participate. We also
considered stakeholder feedback that
suggested we make participation in the
CJR model voluntary, and the model
size necessary to detect at least a 3percent reduction in LEJR episode
spending. Taking these considerations
into account, we considered whether
revising the model to allow for
voluntary participation in all, some, or
39319
none of the 67 selected MSAs would be
feasible.
As discussed in section V. of this
proposed rule, the estimated impact of
the changes to the CJR model proposed
in this proposed rule reduces the overall
estimated savings for performance years
3, 4, and 5 by $90 million. If voluntary
participation was allowed in all of the
67 selected MSAs, the overall estimated
model impact would no longer show
savings, and would likely result in
additional costs to the Medicare
program. If participation was limited to
the proposed 34 mandatory
participation MSAs and voluntary
participation was not allowed in any
MSA, the impact to the overall
estimated model savings over the last
three years of the model would be closer
to $30 million than the $90 million
estimate presented in section V. of this
proposed rule, because our modeling,
which does not include assumptions
about behavioral changes that might
lower fee-for-service spending,
estimates that 60 to 80 hospitals will
choose voluntary participation. Since
we estimate that these potential
voluntary participants would be
expected to earn only positive
reconciliation payments under the
model, these positive reconciliation
payments would offset some of the
savings garnered from mandatory
participants. However, as many current
hospital participants in all of the 67
MSAs are actively invested in the CJR
model, we are proposing to allow
voluntary participation in the 33 MSAs
that were not selected for mandatory
participation and for low-volume and
rural hospitals. We seek comment on
our proposed approach and the
alternatives considered.
A summary of the proposed changes
to the CJR model participation
requirements is shown in Table 4.
TABLE 4—PROPOSED PARTICIPATION REQUIREMENTS FOR HOSPITALS IN THE CJR MODEL
Required to
participate as of
February 1, 2018
May elect
voluntary
participation
Participation
election period
Election
effective
date
Mandatory Participation MSAs
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All IPPS participant hospitals, except rural and low-volume * .......
Rural hospitals * .............................................................................
Low-volume hospitals (see Table 3) ..............................................
Yes .....................
No .......................
No .......................
No .......................
Yes .....................
Yes .....................
n/a
1/1/2018–1/31/2018
1/1/2018–1/31/2018
n/a
2/1/2018
2/1/2018
1/1/2018–1/31/2018
2/1/2018
Voluntary Participation MSAs
All IPPS participant hospitals .........................................................
No .......................
Yes .....................
* Note: Participation requirements are based on the CCN status of the hospital as of January 31, 2018. A change in rural status after the voluntary election period does not affect the participation requirements.
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2. Proposed Codification of CJR ModelRelated Evaluation Participation
Requirements
We note that for the CJR model
evaluation, the data collection methods
and key evaluation research questions
under the proposed reformulated
approach (that is, the proposal for
voluntary opt-in elections discussed in
section III.B.1 of this proposed rule)
would remain similar to the approach
presented in the CJR model final rule.
The evaluation methodology for the CJR
model would be consistent with the
standard Innovation Center approaches
we have taken in other voluntary
models such as the Pioneer Accountable
Care Organization (ACO) Model.
Cooperation and participation in modelrelated activities by all hospitals that
participate in the CJR model would
continue to be extremely important to
the evaluation. Therefore, with respect
to model-related evaluation activities,
we propose to add provisions in
§ 510.410(b)(1)(i)(G) to specify that CMS
may take remedial action if a participant
hospital, or one of its collaborator,
collaboration agent, or downstream
collaboration agent fails to participate in
model-related evaluation activities
conducted by CMS and/or its
contractors for any performance year in
which the hospital participates. We
believe the addition of this provision
would make participation and
collaboration requirements for the CJR
model evaluation clear to all participant
hospitals and in particular to hospitals
that are eligible to elect voluntary
participation. We seek comment on our
proposed regulatory change.
sradovich on DSK3GMQ082PROD with PROPOSALS2
3. Comment Solicitation: Incentivizing
Participation in the CJR Model
In this proposed rule, we are
proposing to make participation in the
CJR model voluntary in 33 MSAs and
for low-volume and rural hospitals in
the remaining 34 MSAs via the
proposed opt-in election policy
discussed in section III.B.1 of this
proposed rule. In order to keep hospitals
in all MSAs selected for participation in
the CJR model actively participating in
the model, we are soliciting comment
on ways to further incentivize eligible
hospitals to elect to continue
participating in the CJR model for the
remaining years of the model and to
further incentivize all participant
hospitals to advance care
improvements, innovation, and quality
for beneficiaries throughout LEJR
episodes.
Additionally, we note that, under the
CJR refinements established in the
January 3, 2017 EPM final rule, the total
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amount of gainsharing payments for a
performance year paid to physicians,
non-physician practitioners, physician
group practices (PGPs), and nonphysician practitioner group practices
(NPPGPs) must not exceed 50 percent of
the total Medicare approved amounts
under the Physician Fee Schedule for
items and services that are furnished to
beneficiaries during episodes that
occurred during the same performance
year for which the CJR participant
hospital accrued the internal cost
savings or earned the reconciliation
payment that comprises the gainsharing
payment being made (§ 510.500(c)(4)).
Similarly, distribution arrangements are
limited as specified in § 510.505(b)(8),
and downstream distribution
arrangements are limited as specified in
§ 510.506(b)(8). These program integrity
safeguards, which are consistent with
the gainsharing caps in other Innovation
Center models, were included to avoid
setting an inappropriate financial
incentive that may result in stinting,
steering or denial of medically
necessary care (80 FR 73415 and 73416).
While we are not proposing in this rule
any changes to the gainsharing caps for
these models, we have heard various
opinions from stakeholders, including
the Medicare Payment Advisory
Commission (MedPAC), on the relative
benefit of such limitations on
gainsharing and in this proposed rule
we are soliciting comment on this
requirement and any alternative
gainsharing caps that may be
appropriate to apply to physicians, nonphysician practitioners, PGPs, and
NPPGPs.
C. Maintaining ICD–CM Codes for
Quality Measures
In the CJR model final rule (80 FR
73474), we discussed how specific
International Classification of Diseases
(ICD)—Clinical Modifications (CM)
procedure codes define group of
procedures included in the Hospitallevel risk-standardized complication
rate (RSCR) following elective primary
total hip arthroplasty (THA) and/or total
knee arthroplasty (TKA) (NQF #1550)
(Hip/Knee Complications) measure. In
discussing quality measures in general,
the ICD–CM codes relative to defining a
measure cohort are updated annually
and are subject to change. For example,
in the EPM final rule (82 FR 389), we
itemized specific ICD–9–CM and ICD–
10–CM codes for Hip/Knee
Complications measure. As quality
measures are refined and maintained,
the ICD–CM code values used to
identify the relevant diagnosis and/or
procedures included in quality
measures can be updated. For example,
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CMS’ Center for Clinical Standards and
Quality (CCSQ) has recently updated
the list of ICD–10 codes used to identify
procedures included in the Hip/Knee
Complications measure. We did not
intend for our preamble discussions of
certain ICD–CM codes used, for
example, to identify procedures
included in the Hip/Knee
Complications measures, and therefore
the PRO cohorts for the CJR model, to
set a policy that would define the
relevant cohorts for the entirety of the
CJR model. We should have also
directed readers to look for the most
current codes on the CMS quality Web
site at https://www.cms.gov/Medicare/
Quality-Initiatives-Patient-AssessmentInstruments/HospitalQualityInits/
Measure-Methodology.html. To ensure
that model participants are aware of
periodic ICD–CM code updates to the
Hip/Knee Complications measure, we
are proposing to clarify that participants
must use the applicable ICD–CM code
set that is updated and released to the
public each calendar year in April by
CCSQ and posted on the Hospital
Quality Initiative Measure Methodology
Web site (https://www.cms.gov/
medicare/Quality-Initiatives-PatientAssessment-Instruments/Hospital
QualityInits/MeasureMethodology.html) for purposes of
reporting each of those measures. CMS
relies on the National Quality Forum
(NQF) measure maintenance update and
review processes to update substantive
aspects of measures every 3 years.
Through NQF’s measure maintenance
process, NQF endorsed measures are
sometimes updated to incorporate
changes that we believe do not
substantially change the nature of the
measures. Examples of such changes
include updated diagnosis or
procedures codes, changes to patient
population, definitions, or extension of
the measure endorsement to apply to
other settings. We believe these types of
maintenance changes are distinct from
more substantive changes and do not
require the use of the agency’s
regulatory process used to update more
detailed aspects of quality measures.
D. Clarification of CJR Reconciliation
Following Hospital Reorganization
Event
In the CJR model final rule (80 FR
73348) rule, we discussed our method of
setting target prices using all historical
episodes that would represent our best
estimate of historical volume and
payments for participant hospitals when
an acquisition, merger, divestiture, or
other reorganization results in a hospital
with a new CCN. When a reorganization
event occurs during a performance year,
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CMS updates the quality-adjusted
episode target prices for the new or
surviving participant hospital
(§ 510.300(b)(4)). Following the end of a
performance year, CMS performs annual
reconciliation calculations in
accordance with the provisions
established in § 510.305. The annual
reconciliation calculations are specific
to the episodes attributable to each
participant hospital entity for that
performance year. The applicable
quality-adjusted episode target price for
such episodes is the quality-adjusted
episode target price that applies to the
episode type as of the anchor
hospitalization admission date
(§ 510.300(a)(3)). For example, if during
a performance year, two participant
hospitals (Hospital A and Hospital B)
merge under the CCN of one of those
two participant hospital’s CCN (Hospital
B’s CCN), (assuming no other
considerations apply) three initial (and
three subsequent) annual reconciliation
calculations for that performance year
are performed: An initial (and
subsequent) reconciliation for Hospital
A for the episodes where the anchor
hospitalization admission occurred
prior to the merger (as determined by
the CCN on the IPPS claim), using
Hospital A’s episode target price for that
time period; an initial (and subsequent)
reconciliation for Hospital B for the
episodes where anchor hospitalization
admission occurred before the merger
(as determined by the CCN on the IPPS
claim), using Hospital B’s episode target
price for that time period; and an initial
(and subsequent) reconciliation for the
post-merger entity (merged Hospitals A
and B) for the episodes where anchor
hospitalization admission occurred on
or after the merger’s effective date, using
the episode target price that time period.
Reorganization events that involve a CJR
model participant hospital and a
hospital that is not participating in the
CJR model and result in the new
organization operating under the CJR
participant hospital’s CCN, would not
affect the reconciliation for the CJR
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participant hospital for episodes that
initiate before the effective date of the
reorganization event. Episodes that
initiate after such reorganization event
would be subject to an updated qualityadjusted episode target price that is
based on historical episodes for the CJR
participant hospital which would
include historical episode expenditures
for all hospitals that are integrated
under the surviving CCN. These policies
have been in effect since the start of the
CJR model on April 1, 2016. To further
clarify this policy for the CJR model, we
propose to add a provision specifying
that separate reconciliation calculations
are performed for episodes that occur
before and after a reorganization that
results in a hospital with a new CCN at
§ 510.305(d)(1). We believe this
clarification would increase
transparency and understanding of the
payment reconciliation processes for the
CJR model. We seek comment on this
proposal.
E. Proposed Adjustment to the Pricing
Calculation for the CJR Telehealth
HCPCS Codes To Include the Facility PE
Values
In the CJR model final rule (80 FR
73450), we established 9 HCPCS Gcodes to report home telehealth
evaluation and management (E/M) visits
furnished under the CJR telehealth
waiver as displayed in Table 5. These
codes have been payable for CJR model
beneficiaries since the CJR model began
on April 1, 2016. Pricing for these 9
codes is updated each calendar year to
reflect the work and malpractice (MP)
relative value units (RVUs) for the
comparable office and other outpatient
E/M visit codes on the Medicare
Physician Fee Schedule (MPFS). As we
stated in the CJR model final rule (80 FR
73450), in finalizing this pricing method
for these codes, we did not include the
practice expense (PE) RVUs of the
comparable office and other outpatient
E/M visit codes in the payment rate for
these unique CJR model services, based
on the belief that practice expenses
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39321
incurred to furnish these services are
marginal or are paid for through other
MPFS services. However, since the
publication of the CJR model final rule,
stakeholders have expressed concern
that the zero value assigned to the PE
RVUs for these codes results in
inaccurate pricing. Stakeholders assert
that there are additional costs related to
the delivery of telehealth services under
the CJR model such as maintaining the
telecommunications equipment,
software and security and that, while
these practice expense costs are not
equivalent to in-person service delivery
costs, they are greater than zero. In
considering the pricing concerns voiced
by stakeholders, we recognize that there
are resource costs in practice expense
for telehealth services furnished
remotely, however, we do not believe
the current PE methodology and data
accurately account for these costs
relative to the PE resource costs for
other services. This belief previously led
us to assign zero PE RVUs in valuing
these services, but because we recognize
that there are some costs that are not
being accounted for by the current
pricing for these CJR model codes, we
believe an alternative to assigning zero
PE RVUs would be to use the facility PE
RVUs for the analogous in-person
services. While we acknowledge that
assigning the facility PE RVUs would
not provide a perfect reflection of
practice resource costs for remote
telehealth services under the CJR model,
in the absence of more specific
information, we believe it is likely a
better proxy for such PE costs than zero.
Therefore, we are proposing to use the
facility PE RVUs for the analogous
services in pricing the 9 CJR HCPCS G
codes shown in Table 5. Additionally,
we are proposing to revise
§ 510.605(c)(2) to reflect the addition of
the RVUs for comparable codes for the
facility PE to the work and MP RVUs we
are currently using for the basis for
payment of the CJR telehealth waiver G
codes.
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TABLE 5—HCPCS CODES FOR TELEHEALTH VISITS FOR CJR MODEL BENEFICIARIES IN HOME OR PLACE OF RESIDENCE
Work and MP RVUs equal to
those of the corresponding
office/outpatient E/M visit
CPT code for same calendar
year under the PFS; PE
RVUs equal to the facility
values for each
HCPCS
Code No.
Long descriptor
Short descriptor
G9481 .............
Remote in-home visit for the evaluation and management
of a new patient for use only in the Medicare-approved
Comprehensive Care for Joint Replacement model,
which requires these 3 key components:
• A problem focused history.
• A problem focused examination.
• Straightforward medical decision making, furnished
in real time using interactive audio and video technology.
Counseling and coordination of care with other physicians,
other qualified health care professionals or agencies are
provided consistent with the nature of the problem(s)
and the needs of the patient or the family or both. Usually, the presenting problem(s) are self limited or minor.
Typically, 10 minutes are spent with the patient or family
or both via real time, audio and video intercommunications technology.
Remote in-home visit for the evaluation and management
of a new patient for use only in the Medicare-approved
Comprehensive Care for Joint Replacement model,
which requires these 3 key components:
• An expanded problem focused history.
• An expanded problem focused examination.
• Straightforward medical decision making, furnished
in real time using interactive audio and video technology. Counseling and coordination of care with
other physicians, other qualified health care professionals or agencies are provided consistent with the
nature of the problem(s) and the needs of the patient or the family or both. Usually, the presenting
problem(s) are of low to moderate severity. Typically, 20 minutes are spent with the patient or family
or both via real time, audio and video intercommunications technology.
Remote in-home visit for the evaluation and management
of a new patient for use only in the Medicare-approved
Comprehensive Care for Joint Replacement model,
which requires these 3 key components:
• A detailed history.
• A detailed examination.
• Medical decision making of low complexity, furnished in real time using interactive audio and video
technology. Counseling and coordination of care
with other physicians, other qualified health care
professionals or agencies are provided consistent
with the nature of the problem(s) and the needs of
the patient or the family or both. Usually, the presenting problem(s) are of moderate severity. Typically, 30 minutes are spent with the patient or family
or both via real time, audio and video intercommunications technology.
Remote in-home visit for the evaluation and management
of a new patient for use only in the Medicare-approved
Comprehensive Care for Joint Replacement model,
which requires these 3 key components:
• A comprehensive history.
• A comprehensive examination.
Remote E/M new pt 10 mins ......
99201
Remote E/M new pt 20 mins ......
99202
Remote E/M new pt 30 mins ......
99203
Remote E/M new pt 45 mins ......
99204
G9482 .............
G9483 .............
sradovich on DSK3GMQ082PROD with PROPOSALS2
G9484 .............
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39323
TABLE 5—HCPCS CODES FOR TELEHEALTH VISITS FOR CJR MODEL BENEFICIARIES IN HOME OR PLACE OF
RESIDENCE—Continued
HCPCS
Code No.
Long descriptor
G9485 .............
G9486 .............
sradovich on DSK3GMQ082PROD with PROPOSALS2
G9487 .............
VerDate Sep<11>2014
Short descriptor
• Medical decision making of moderate complexity,
furnished in real time using interactive audio and
video technology. Counseling and coordination of
care with other physicians, other qualified health
care professionals or agencies are provided consistent with the nature of the problem(s) and the
needs of the patient or the family or both. Usually,
the presenting problem(s) are of moderate to high
severity. Typically, 45 minutes are spent with the
patient or family or both via real time, audio and
video intercommunications technology.
Remote in-home visit for the evaluation and management
of a new patient for use only in the Medicare-approved
Comprehensive Care for Joint Replacement model,
which requires these 3 key components:
• A comprehensive history.
• A comprehensive examination.
• Medical decision making of high complexity, furnished in real time using interactive audio and video
technology. Counseling and coordination of care
with other physicians, other qualified health care
professionals or agencies are provided consistent
with the nature of the problem(s) and the needs of
the patient or the family or both. Usually, the presenting problem(s) are of moderate to high severity.
Typically, 60 minutes are spent with the patient or
family or both via real time, audio and video intercommunications technology.
Remote in-home visit for the evaluation and management
of an established patient for use only in the Medicareapproved Comprehensive Care for Joint Replacement
model, which requires at least 2 of the following 3 key
components:
• A problem focused history.
• A problem focused examination.
• Straightforward medical decision making, furnished
in real time using interactive audio and video technology. Counseling and coordination of care with
other physicians, other qualified health care professionals or agencies are provided consistent with the
nature of the problem(s) and the needs of the patient or the family or both. Usually, the presenting
problem(s) are self limited or minor. Typically, 10
minutes are spent with the patient or family or both
via real time, audio and video intercommunications
technology.
Remote in-home visit for the evaluation and management
of an established patient for use only in the Medicareapproved Comprehensive Care for Joint Replacement
model, which requires at least 2 of the following 3 key
components:
• An expanded problem focused history.
• An expanded problem focused examination.
• Medical decision making of low complexity, furnished in real time using interactive audio and video
technology. Counseling and coordination of care
with other physicians, other qualified health care
professionals or agencies are provided consistent
with the nature of the problem(s) and the needs of
the patient or the family or both. Usually, the presenting problem(s) are of low to moderate severity.
Typically, 15 minutes are spent with the patient or
family or both via real time, audio and video intercommunications technology.
19:57 Aug 16, 2017
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Frm 00015
Work and MP RVUs equal to
those of the corresponding
office/outpatient E/M visit
CPT code for same calendar
year under the PFS; PE
RVUs equal to the facility
values for each
Fmt 4701
Remote E/M new pt 60 mins ......
99205
Remote E/M est. pt 10 mins .......
99212
Remote E/M est. pt 15 mins .......
99213
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TABLE 5—HCPCS CODES FOR TELEHEALTH VISITS FOR CJR MODEL BENEFICIARIES IN HOME OR PLACE OF
RESIDENCE—Continued
Work and MP RVUs equal to
those of the corresponding
office/outpatient E/M visit
CPT code for same calendar
year under the PFS; PE
RVUs equal to the facility
values for each
HCPCS
Code No.
Long descriptor
Short descriptor
G9488 .............
Remote in-home visit for the evaluation and management
of an established patient for use only in the Medicareapproved Comprehensive Care for Joint Replacement
model, which requires at least 2 of the following 3 key
components:
• A detailed history.
• A detailed examination.
• Medical decision making of moderate complexity,
furnished in real time using interactive audio and
video technology. Counseling and coordination of
care with other physicians, other qualified health
care professionals or agencies are provided consistent with the nature of the problem(s) and the
needs of the patient or the family or both. Usually,
the presenting problem(s) are of moderate to high
severity. Typically, 25 minutes are spent with the
patient or family or both via real time, audio and
video intercommunications technology.
Remote in-home visit for the evaluation and management
of an established patient for use only in the Medicareapproved Comprehensive Care for Joint Replacement
model, which requires at least 2 of the following 3 key
components:
• A comprehensive history.
• A comprehensive examination.
• Medical decision making of high complexity, furnished in real time using interactive audio and video
technology. Counseling and coordination of care
with other physicians, other qualified health care
professionals or agencies are provided consistent
with the nature of the problem(s) and the needs of
the patient or the family or both. Usually, the presenting problem(s) are of moderate to high severity.
Typically, 40 minutes are spent with the patient or
family or both via real time, audio and video intercommunications technology.
Remote E/M est. pt 25 mins .......
99214
Remote E/M est. pt 40 mins .......
99215
G9489 .............
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F. Clinician Engagement Lists
1. Background for Submission of
Clinician Engagement Lists
Under the Quality Payment Program,
the Advanced APM track of the CJR
model does not include eligible
clinicians on a Participation List; rather
the CJR Advanced APM track currently
includes eligible clinicians on an
Affiliated Practitioner List as defined
under § 414.1305 and described under
§ 414.1425(a)(2) of the agency’s Quality
Payment Program regulations. As such,
the Affiliated Practitioner List for the
CJR model is the ‘‘CMS-maintained list’’
of eligible clinicians that have ‘‘a
contractual relationship with the
Advanced APM Entity [for CJR, the
participant hospital] for the purposes of
supporting the Advanced APM Entity’s
quality or cost goals under the
Advanced APM.’’ As specified in our
regulations at § 414.1425(a)(2), CMS will
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use this list to identify the eligible
clinicians who will be assessed as
Qualifying APM Participants (QPs) for
the year. CMS will make QP
determinations individually for these
eligible clinicians as specified in
§§ 414.1425(b)(2), (c)(4), and 414.1435.
In the EPM final rule, we stated that
a list of physicians, nonphysician
practitioners, or therapists in a sharing
arrangement, distribution arrangement,
or downstream distribution
arrangement, as applicable, would be
considered an Affiliated Practitioner
List of eligible clinicians who are
affiliated with and support the
Advanced APM Entity in its
participation in the Advanced APM for
purposes of the Quality Payment
Program. An in-depth discussion of how
the clinician financial arrangement list
is considered an Affiliated Practitioner
List can be found in section V.O. of the
EPM final rule (82 FR 558 through 563).
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The clinician financial arrangements list
(§ 510.120(b)) will be used by CMS to
identify eligible clinicians for whom we
would make a QP determination based
on services furnished through the
Advanced APM track of the CJR model.
Stakeholders have expressed a desire
for model changes that would also
include in the clinician financial
arrangement list physicians, nonphysician practitioners, and therapists
without a financial arrangement under
the CJR model, but who are affiliated
with and support the Advanced APM
Entity in its participation in the
Advanced APM for purposes of the
Quality Payment Program.
We agree with stakeholders that these
physicians, non-physician practitioners,
and therapists should have their
contributions to the Advanced APM
Entity’s participation in the Advanced
APM recognized under the Quality
Payment Program; however, since these
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individuals do not have financial
arrangements with the participant
hospital, to also include them on the
clinician financial arrangement list
would be misleading, and could create
confusion when CJR model participant
hospitals submit lists to CMS.
2. Proposed Clinician Engagement List
Requirements
To increase opportunities for eligible
clinicians supporting CJR model
participant hospitals by performing CJR
model activities and who are affiliated
with participant hospitals to be
considered QPs, we are proposing that
each physician, nonphysician
practitioner, or therapist who is not a
CJR collaborator during the period of the
CJR model performance year specified
by CMS, but who does have a
contractual relationship with the
participant hospital based at least in
part on supporting the participant
hospital’s quality or cost goals under the
CJR model during the period of the
performance year specified by CMS,
would be added to a clinician
engagement list.
In addition to the clinician financial
arrangement list that is considered an
Affiliated Practitioner List for purposes
of the Quality Payment Program, we
propose the clinician engagement list
would also be considered an Affiliated
Practitioner List. The clinician
engagement list and the clinician
financial arrangement list would be
considered together an Affiliated
Practitioner List and would be used by
CMS to identify eligible clinicians for
whom we would make a QP
determination based on services
furnished through the Advanced APM
track of the CJR model. As specified in
§ 414.1425, as of our regulations,
adopted in the Calendar Year (CY) 2017
Quality Payment Program final rule (81
FR 77551) (hereinafter referred to as the
2017 QPP final rule), those physicians,
nonphysician practitioners, or therapists
who are included on the CJR model
Affiliated Practitioner List as of March
31, June 30, or August 31 of a QP
performance period would be assessed
to determine their QP status for the year.
As discussed in the 2017 QPP final rule
(81 FR 77439 and 77440), for clinicians
on an Affiliated Practitioner List, we
determine whether clinicians meet the
payment amount or patient count
thresholds to be considered QPs (or
Partial QPs) for a year by evaluating
whether individual clinicians on an
Affiliated Practitioner List have
sufficient payments or patients flowing
through the Advanced APM; we do not
make any determination at the APM
Entity level for Advanced APMs in
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which eligible clinicians are not
identified on a Participation List, but are
identified on an Affiliated Practitioner
List. CMS makes the QP determination
based on Part B claims data, so
clinicians need not track or report
payment amount or patient count
information to CMS.
This proposal would broaden the
scope of eligible clinicians that are
considered Affiliated Practitioners
under the CJR model to include those
without a financial arrangement under
the CJR model but who are either
directly employed by or contractually
engaged with a participant hospital to
perform clinical work for the participant
hospital when that clinical work, at
least in part, supports the cost and
quality goals of the CJR model. We
propose that the cost and quality goals
of the additional affiliated practitioners
who are identified on a clinician
engagement list because they are
contracted with a participant hospital
must include activities related to CJR
model activities, that is, activities
related to promoting accountability for
the quality, cost, and overall care for
beneficiaries during LEJR episodes
included in the CJR model, including
managing and coordinating care;
encouraging investment in
infrastructure, enabling technologies,
and redesigned care processes for high
quality and efficient service delivery;
the provision of items and services
during a CJR episode in a manner that
reduces costs and improves quality; or
carrying out any other obligation or duty
under the CJR model.
Like the requirements of the clinician
financial arrangement lists specified at
§ 510.120(b), for CMS to make QP
determinations for eligible clinicians
based on services furnished through the
CJR Advanced APM track, we would
require that accurate information about
each physician, nonphysician
practitioner, or therapist who is not a
CJR collaborator during the period of the
CJR model performance year specified
by CMS, but who is included on a
clinician engagement list, be provided
to CMS in a form and manner specified
by CMS on a no more than quarterly
basis. Thus, we propose that each
participant hospital in the Advanced
APM track of the CJR model submit to
CMS a clinician engagement list in a
form and manner specified by CMS on
a no more than quarterly basis. We
propose this list must include the
following information on eligible
clinicians for the period of the CJR
model performance year specified by
CMS:
• For each physician, nonphysician
practitioner, or therapist who is not a
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39325
CJR collaborator during the period of the
CJR model performance year specified
by CMS but who does have a
contractual relationship with a
participant hospital based at least in
part on supporting the participant
hospital’s quality or cost goals under the
CJR model during the period of the CJR
model performance year specified by
CMS:
++ The name, TIN, and NPI of the
individual.
++ The start date and, if applicable,
the end date for the contractual
relationship between the individual and
participant hospital.
Further, we propose that if there are
no individuals that meet the
requirements to be reported, as specified
in any of § 510.120 (b)(1) through (3) of
the EPM final rule or § 510.120(c) as
proposed here, the participant hospital
must attest in a form and manner
required by CMS that there are no
individuals to report.
Given that this proposal would
require submission of a clinician
engagement list, or an attestation that
there are no eligible clinicians to be
included on such a list, to reduce
burden on participant hospitals, we
would collect information for the
clinician engagement list and clinician
financial arrangement list at the same
time.
We seek comments on the proposal
for submission of this information. We
are especially interested in comments
about approaches to information
submission, including the periodicity
and method of submission to CMS that
would minimize the reporting burden
on participant hospitals while providing
CMS with sufficient information about
eligible clinicians to facilitate QP
determinations.
For each participant hospital in the
CJR Advanced APM track, we propose
that the participant hospital must
maintain copies of its clinician
engagement lists and supporting
documentation (that is, copies of
employment letters or contracts) of its
clinical engagement lists submitted to
CMS. Because we would use these lists
to develop Affiliated Practitioner Lists
used for purposes of making QP
determinations, these documents would
be necessary to assess the completeness
and accuracy of materials submitted by
a participant hospital and to facilitate
monitoring and audits. For the same
reason, we further propose that the
participant hospital must retain and
provide access to the required
documentation in accordance with
§ 510.110.
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G. Clarification of Use of Amended
Composite Quality Score Methodology
During CJR Model Performance Year 1
Subsequent Reconciliation
We conducted the initial
reconciliation for performance year 1 of
the CJR model in early 2017, and expect
to make reconciliation payments to CJR
participant hospitals by the end of
September 2017 to accommodate the
performance year 1 appeals process
timelines. We will conduct the
subsequent reconciliation calculation
for performance year 1 of the CJR model
beginning in the first quarter of 2018,
which may result in additional amounts
to be paid to participant hospitals or a
reduction to the amount that was paid
for performance year 1. However, the
results of the performance year 1
subsequent reconciliation calculations
will be combined with the performance
year 2 initial reconciliation results
before reconciliation payment or
repayment amounts are processed for
payment or collection. Changes to the
CJR model established in the EPM final
rule impact this process.
The improvements to the CJR model
quality measures and composite quality
score methodology, which were
finalized in the EPM final rule (82 FR
524 through 526), were intended to be
effective before the CJR model’s
performance year 1 initial
reconciliation. However, as noted in
section II. of this proposed rule, the
effective date for certain EPM final rule
provisions, including those amending
§§ 510.305 and 510.315 to improve the
quality measures and composite quality
score methodology, were delayed until
May 20, 2017. As a result, the CJR
reconciliation reports issued in April
2017 were created in accordance with
the provisions of §§ 510.305 and
510.315 in effect as of April 2017; that
is, the provisions finalized in the CJR
model final rule. In early 2018, we
would perform the performance year 1
subsequent reconciliation calculation in
accordance with the provisions
§§ 510.305 and 510.315 in effect as of
early 2018, that is, established in the
EPM final rule. Applying the provisions
established in the EPM final rule to the
performance year 1 subsequent
reconciliation calculation may result in
significant differences between the
reconciliation payments calculated
during the performance year 1 initial
reconciliation and the performance year
1 subsequent reconciliation. We
anticipate that these differences will be
greater than those that would be
expected as a result of using more
complete claims and programmatic data
that will be available for the subsequent
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reconciliation (due to the additional 12
months of time that will occur between
the initial and subsequent reconciliation
calculations), more accurate
identification of model overlap and
exclusion of episodes, as well as
factoring in adjustments to account for
shared savings payments, and postepisode spending, as specified in
§ 510.305(i). Specifically, the
methodology used to determine the
quality-adjusted target price for the
performance year 1 subsequent
reconciliation calculation will differ
from the methodology used to
determine the quality-adjusted target
price for the performance year 1 initial
reconciliation calculation as follows:
The quality-adjusted target price would
be recalculated to apply the amended
reductions to the effective discount
factors (§ 510.315(f)), which would be
determined after recalculating the
composite quality scores, including
applying more generous criteria for
earning quality improvement points
(that is, a 2 decile improvement rather
than 3 decile improvement as specified
in amended § 510.315(d)). Using the
recalculated quality-adjusted target
price, the net payment reconciliation
amount (NPRA) would be recalculated
and will include application of postepisode spending reductions
(§ 510.305(j)), as necessary, after
determining the limitations on loss or
gain. Thus, calculating performance
year 1 reconciliation payments using
these two different provisions may
result in a range of upward or
downward adjustments to participant
hospitals’ performance year 1 payment
amounts. We note that a downward
adjustment to the performance year 1
payment amounts would require
payment recoupment, if offset against a
performance year 2 initial reconciliation
payment amount is not feasible, which
may be burdensome for participant
hospitals.
In developing this proposed rule, we
also considered whether there might be
benefit in further delaying the
amendments to §§ 510.305 and 510.315
such that the same calculations would
be used for both the performance year
1 initial reconciliation and the
subsequent performance year 1
reconciliation, and the use of the
amended calculations would begin with
the performance year 2 initial
reconciliation. We believe such an
approach would impact future CJR
model implementation and evaluation
activities. Because determining the
performance year 2 composite quality
score considers the hospital’s quality
score improvement from its
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performance year 1 score, using
different methodologies across
performance years would require a
mechanism to account for differences in
the quality score methodology, for
example we would have to develop a
reliable crosswalk approach. If we were
to develop and use a crosswalk
approach, participants and other
stakeholders would need to be informed
about the crosswalk methodology in
order to validate data analyses across
performance years and that usage of the
crosswalk would be ongoing throughout
the model’s duration for consistency
across performance years. This
methodology could add substantial
complexity to this time-limited model.
We also considered that the composite
quality score for some participant
hospitals may be higher under the
revised scoring methodology. Delaying
use of the revised scoring methodology
may disadvantage these participants if
their composite quality score would be
higher and result in a more favorable
discount percentage or allow the
hospital to qualify for a reconciliation
payment. Therefore, we believe the best
approach is to apply the quality
specifications as established in the EPM
final rule (that is, the amendments to
§§ 510.305 and 510.315 that became
effective May 20, 2017) to performance
year 1 subsequent reconciliation
calculations to ensure that
reconciliation calculations for
subsequent performance years will be
calculated using the same methodology
and to improve consistency across
performance years for quality
improvement measurement. Thus, for
the reasons noted previously, we are not
proposing to change the amendments to
§§ 510.305 and 510.315 that became
effective May 20, 2017. We seek
comment on whether using an
alternative approach, such as the quality
composite score methodology from the
CJR model final rule for the performance
year 1 subsequent reconciliation, would
ensure better consistency for analyses
across CJR performance years.
H. Clarifying and Technical Changes
Regarding the Use of the CMS Price
(Payment) Standardization Detailed
Methodology
Based on questions we received from
participant hospitals during the
performance year 1 reconciliation
process, we are proposing to make two
technical changes to the CJR model
regulations to clarify the use of the CMS
Price (Payment) Standardization
Detailed Methodology, posted on the
QualityNet Web site at https://
www.qualitynet.org/dcs/Content
Server?c=Page&pagename=Qnet
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Public%2FPage%2FQnetTier4&cid=
1228772057350, in the calculation of
target prices and actual episode
spending. This pricing standardization
approach is the same as that used for the
Hospital Value-Based Purchasing
Program’s (HVBP) Medicare spending
per beneficiary metric. In section
III.C.3.a. of the CJR model final rule (80
FR 73331 through 73333), we finalized
how we would operationalize the
exclusion of the various special
payment provisions in calculating CJR
model episode expenditures, both
historical episode spending and
performance year episode spending, by
relying upon the CMS Price (Payment)
Standardization Detailed Methodology
with modifications. However, we did
not clearly articulate this finalized
policy in the regulations at 42 CFR part
510. Thus, we are proposing the
following technical changes to bring the
regulatory text into conformity with our
intended policy and to reduce potential
stakeholder uncertainty about how the
price (payment) standardization
methodology is used. We are proposing
to insert ‘‘standardized’’ into the
definition of actual episode payment in
§ 510.2, and insert ‘‘with certain
modifications’’ into § 510.300(b)(6) to
account for the modifications we must
make to the standardization
methodology to ensure all pricing
calculations are consistent with our
finalized policies.
IV. Collection of Information
Requirements
As stated in section 1115A(d)(3) of the
Act, Chapter 35 of title 44, United States
Code, shall not apply to the testing and
evaluation of models under section
1115A of the Act. As a result, the
information collection requirements
contained in this proposed rule need
not be reviewed by the Office of
Management and Budget. However, we
have, summarized the anticipated cost
burden associated with the information
collection requirements in the
Regulatory Impact Analysis section of
this proposed rule.
sradovich on DSK3GMQ082PROD with PROPOSALS2
V. Regulatory Impact Analysis
A. Introduction
We have examined the impacts of this
rule as required by Executive Order
12866 on Regulatory Planning and
Review (September 30, 1993), Executive
Order 13563 on Improving Regulation
and Regulatory Review (January 18,
2011), the Regulatory Flexibility Act
(RFA) (September 19, 1980, Pub. L. 96–
354), section 1102(b) of the Social
Security Act, section 202 of the
Unfunded Mandates Reform Act of 1995
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19:57 Aug 16, 2017
Jkt 241001
(March 22, 1995; Pub. L. 104–4),
Executive Order 13132 on Federalism
(August 4, 1999) and the Congressional
Review Act (5 U.S.C. 804(2)), and
Executive Order 13771 on Reducing
Regulation and Controlling Regulatory
Costs (January 30, 2017).
Executive Orders 12866 and 13563
direct agencies to assess all costs and
benefits of available regulatory
alternatives and, if regulation is
necessary, to select regulatory
approaches that maximize net benefits
(including potential economic,
environmental, public health and safety
effects, distributive impacts, and
equity). A regulatory impact analysis
(RIA) must be prepared for major rules
with economically significant effects
($100 million or more in any 1 year).
This proposed rule proposes to cancel
the EPMs and the CR incentive payment
model in advance of their start date and
proposes several revisions to the design
of the CJR model; these proposals
impact a subset of hospitals under the
IPPS. Therefore, it would have a
relatively small economic impact; as a
result, this proposed rule does not reach
the $100 million threshold and thus is
neither an ‘‘economically significant’’
rule under E.O. 12866, nor a ‘‘major
rule’’ under the Congressional Review
Act.
B. Statement of Need
As discussed previously, review and
reevaluation of policies and programs,
as well as revised rulemaking, are
within an agency’s discretion, especially
after a change in administration occurs.
After review and reevaluation of the CJR
model final rule, the EPM final rule and
the public comments we received in
response to the March 21, 2017 IFC, in
addition to other considerations, we
have determined that it is necessary to
propose to rescind the regulations at 42
CFR part 512 and to reduce the
geographic scope of the CJR model for
the following reasons. First, we believe
that requiring hospitals to participate in
additional episode models at this time
is not in the best interest of the agency
or affected providers. We are concerned
that engaging in large mandatory
episode payment model efforts at this
time may impede our ability to pursue
and engage providers, such as hospitals,
in future voluntary efforts. Similarly, we
also believe that reducing the number of
providers required to participate in the
CJR model would allow us to continue
to evaluate the effects of such a model
while limiting the geographic reach of
our current mandatory models. Finally,
we believe that canceling the EPMs and
CR incentive payment model, as well as
altering the scope of the CJR model,
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offers CMS maximum flexibility to
design alternative episode-based models
and make potential improvements to
these models as suggested by
stakeholders, while still allowing us to
test and evaluate the impact of the CJR
model on the quality of care and
expenditures.
This proposed rule is also necessary
to propose improvements to the CJR
model for performance years 3, 4, and
5. We are proposing a few technical
refinements and clarifications for
certain payment, reconciliation and
quality provisions, and a change to the
criteria for the Affiliated Practitioner
List to broaden the CJR Advanced APM
track to additional eligible clinicians.
We believe these proposed refinements
would address operational issues
identified since the start of the CJR
model.
C. Anticipated Effects
In section III. of the preamble to this
proposed rule, we discuss our proposals
to amend the regulations governing the
CJR model. We present the following
estimated overall impact of these
proposed changes to the CJR model.
Table 6 summarizes the newly
calculated estimated impact for the CJR
model for the last 3 years of the model.
The modeling methodology for
provider performance and participation
is consistent with the methodology used
in modeling the CJR impacts in the EPM
final rule (82 FR 596). However, we
updated our analysis to include an optin option for hospitals in 33 of the 67
MSAs selected for participation in the
CJR model (all but 4 of these MSAs are
from the lower cost groups), while
maintaining mandatory participation for
the remaining 34 MSAs (all of which are
from the higher cost groups), and
allowing for the exclusion of lowvolume and rural hospitals in these 34
MSAs from mandatory participation and
allowing them to choose voluntary
participation (opt-in). We would expect
the number of mandatory participating
hospitals from year 3 forward to
decrease from approximately 700,
which is approximately the number of
current CJR participants, to
approximately 393. We assumed that if
a hospital would exceed its target
pricing such that it would incur an
obligation of repayment to CMS of 3
percent or more in a given year, that
hospital would not elect voluntary
participation in the model for the final
three performance years. We assumed
no low-volume providers would
participate, noting that including them
in impacts would not have any
noticeable effects due to their low
claims volume. For purposes of
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identifying CJR rural hospitals for this
impact, we used the 2017 IPPS
§ 412.103 rural reclassification list. We
found only one provider in the 34
mandatory MSAs with an active rural
reclassification and this provider was
also on the low-volume hospital list and
was not included in the impacts. The
likelihood of voluntary participation
linearly increases based on an upper
bound of 3 percent bonus, but the
modeling assumes that 25 percent of
hospitals in the voluntary MSAs would
not consider participation so that the
likelihood of participation for each
hospital is capped at 75 percent; we
expect 60 to 80 hospitals to elect
voluntary participation in the model.
We seek comment on our assumptions
about the number of hospitals that
would elect voluntary participation in
the CJR model. Due to a lack of available
data, we did not account for participant
investment in the impact analysis model
we used for this proposed rule.
However, we would expect that those
who choose to voluntarily participate
would have made investments in the
CJR model that enable them to perform
well and that they would anticipate
earning positive reconciliation
payments. For those hospitals choosing
not to voluntarily participate, we would
expect that the cost of any investments
they may have made based on their
participation in performance years 1
and 2 of the CJR model would be
outweighed by the reconciliation
payment obligations they would expect
to incur if they continued to participate.
The 60 to 80 participants we expect to
continue participating in the model
through the voluntary election process
are not included in our previous
estimate of 393 CJR participants in the
mandatory MSAs. Thus, in total we
expect approximately 450 to 470
participants in the CJR model for the
final three performance years. The
participation parameters were chosen to
reflect both the anticipated risk aversion
of providers, and an expectation that
many participants do not remain in an
optional model or demonstration when
there is an expectation that the hospital
would incur an obligation of repayment
to CMS. These assumptions reflect the
experience with other models and
demonstrations. The value of 3 percent
may be somewhat larger than the level
of repayment at which providers would
opt-in, but the value was chosen to
allow for the uncertainty of expected
claims. We note that the possibility of
shifting episodes from CJR model
participant hospitals to low-volume or
other non-participating hospitals exists
and that we did not include any
assumptions of this potential behavior
in our financial impact modeling. We
seek comment on our model
assumptions that shifting of episodes
will not occur. The new calculations
estimate that the CJR model would
result in a net Medicare program savings
of approximately $204 million over the
3 remaining performance years (2018
through 2020). This represents a
reduction in savings of approximately
$90 million from the estimated net
financial impacts of the CJR model in
the EPM final rule (82 FR 603).
Our previous analyses of the CJR
model did not explicitly model for
utilization changes, such as
improvements in the efficiency of
service during episodes. However, these
behavioral changes would have minimal
effect on the Medicare financial
impacts. If the actual costs for an
episode are below the discounted
bundled payment amount, then CMS
distributes the difference between these
two amounts to the participant hospital,
up to a capped amount. Similarly, if
actual costs for an episode are above the
discounted bundled payment amount,
then the participant hospital pays CMS
the difference between these amounts,
up to a capped amount. Due to the
uncertainty of estimating the impacts of
this model, actual results could be
higher or lower than this estimate.
TABLE 6—COMPARISON OF INITIAL ESTIMATE OF THE IMPACT ON THE MEDICARE PROGRAM OF THE CJR MODEL WITH
REVISED ESTIMATES
[Figures are in $ millions, negative values represent savings]
Year
2018
Initial CJR Estimate .........................................................................................
Revised CJR Estimate .....................................................................................
Change ............................................................................................................
2019
¥61
¥38
22
2020
¥109
¥77
32
¥125
¥88
36
Total
¥294
¥204
90
Note: The initial estimate includes the changes to the CJR model finalized in the EPM final rule (82 FR 603). The 2016 and 2017 initial estimate is not impacted by the proposed changes to the CJR model in this proposed rule. The total column reflects 2018 through 2020. Totals do
not necessarily equal the sums of rounded components.
Our analysis presents the cost and
transfer payment effects of this
proposed rule to the best of our ability.
sradovich on DSK3GMQ082PROD with PROPOSALS2
D. Effects on Beneficiaries
We believe that the proposal to cancel
the EPMs and CR incentive payment
model would not affect beneficiaries’
freedom of choice to obtain healthcare
services from any individual or
organization qualified to participate in
the Medicare program, including
providers that are making care
improvements within their
communities. Although these models
seek to incentivize care redesign and
collaboration throughout the inpatient
and post-acute care spectrum, the
models have not yet begun. As the
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current baseline assumes these models
would become effective on January 1,
2018, and that these models would
incentivize care improvements that
would likely result in an increase in
quality of care for beneficiaries, it is
possible that the proposal to cancel
these models could cause hospitals that
potentially made improvements in care
in anticipation of the start of these
models to delay or cease these
investments, which could result in a
reversal of any recent quality
improvements. However, we believe the
concerns raised by stakeholders and the
lack of time to consider design
improvements for these models prior to
the January 1, 2018 start date outweigh
potential reversal of any recent
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improvements in care potentially made
by some hospitals and warrant
cancellation of these models at this time
while we engage with stakeholders to
identify future tests for bundled
payments and incentivizing high value
care.
We believe that the proposed changes
to the CJR model discussed in this
proposed rule, specifically focusing the
model on higher cost MSAs in which
participation would continue to be
mandatory and allowing low-volume
and rural hospitals and all participant
hospitals in lower cost MSAs to choose
voluntary participation, would maintain
the potential benefits of the CJR model
for beneficiaries in many areas while
providing a substantial number of
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hospitals with increased flexibility to
better focus on priority needs of the
beneficiaries they serve. Specifically,
low-volume and rural hospitals as well
as other hospitals in the 33 voluntary
participation MSAs (which are
relatively more efficient areas) could
elect to participate in the CJR model if
they believe that doing so best meets
their organization’s strategic priorities
for serving the beneficiaries in their
community. Alternatively, if these
hospitals do not believe continued
participation in the CJR model would
benefit their organizational goals and
local patient care priorities, they can
elect not to opt-in for the remainder of
the model. We believe that beneficiaries
in the service areas of the hospitals that
would be allowed to choose to
participate in the CJR model under our
proposal may have an ongoing benefit
from the care redesign investments
these hospitals have already made
during the first 2 years of the CJR model.
Overall, we believe the refinements to
the CJR model proposed in this
proposed rule do not materially alter the
potential effects of the model on
beneficiaries. However, we acknowledge
the possibility that the improved quality
of care that was likely to have occurred
during performance years 1 and 2 of the
CJR model may be curtailed for
beneficiaries that receive care at
hospitals that do not elect to continue
participation in the CJR model.
E. Effects on Small Rural Hospitals
The changes to the CJR model
proposed in this proposed rule do not
substantially alter our previous impacts
of the impact on small, geographically
rural hospitals specified in either the
EPM final rule (82 FR 606) and the CJR
model final rule (80 FR 73538) because
we continue to believe that few
geographically rural hospitals will be
included in the CJR model. In addition,
the proposal to allow all rural hospitals
(as defined in § 510.2) that are not
otherwise excluded the opportunity to
elect to opt-in to the CJR model instead
of having a mandatory participation
requirement may further reduce the
likelihood that rural hospitals would be
included in the model. We solicit public
comment on our estimates and analysis
of the impact of our proposals on small
rural hospitals.
F. Effects on Small Entities
The RFA requires agencies to analyze
options for regulatory relief of small
entities, if a rule has a significant impact
on a substantial number of small
entities. For purposes of the RFA, small
entities include small businesses,
nonprofit organizations, and small
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governmental jurisdictions. We estimate
that most hospitals and most other
providers and suppliers are small
entities, either by virtue of their
nonprofit status or by qualifying as
small businesses under the Small
Business Administration’s size
standards (revenues of less than $7.5 to
$38.5 million in any 1 year; NAIC
Sector—62 series). States and
individuals are not included in the
definition of a small entity. For details,
see the Small Business Administration’s
Web site at https://www.sba.gov/content/
smallbusiness-size-standards.
For purposes of the RFA, we generally
consider all hospitals and other
providers and suppliers to be small
entities. We believe that the provisions
of this proposed rule relating to acute
care hospitals would have some effects
on a substantial number of other
providers involved in these episodes of
care including surgeons and other
physicians, skilled nursing facilities,
physical therapists, and other providers.
Although we acknowledge that many of
the affected entities are small entities,
and the analysis discussed throughout
this proposed rule discusses aspects of
episode payment models that may or
would affect them, we have no reason
to assume that these effects would reach
the threshold level of 3 percent of
revenues used by HHS to identify what
are likely to be ‘‘significant’’ impacts.
We assume that all or almost all of these
entities would continue to serve these
patients, and to receive payments
commensurate with their cost of care.
Hospitals currently experience frequent
changes to payment (for example, as
both hospital affiliations and preferred
provider networks change) that may
impact revenue, and we have no reason
to assume that this would change
significantly under the changes
proposed in this rule.
Accordingly, we have determined that
this proposed rule will not have a
significant impact on a substantial
number of small entities. We solicit
public comments on our estimates and
analysis of the impact of our proposals
on those small entities.
G. Effects of Information Collection
The changes proposed in this
proposed rule would have a minimal
additional burden of information
collection for CJR model participant
hospitals. The two areas which this
proposed rule may increase participant
burden include providing clinician
engagement lists and submitting opt-in
documentation (for eligible hospitals
who choose to opt-in to the CJR model).
Clinician engagement list submission
for the CJR model would require that
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participants submit on a no more than
quarterly basis a list of physicians,
nonphysician practitioners, or therapists
who are not a CJR model collaborator
during the period of the CJR model
performance year specified by CMS but
who do have a contractual relationship
with a CJR model participant hospital
based at least in part on supporting the
participant hospital’s quality or cost
goals under the CJR model during the
period of the performance year specified
by CMS.
For hospitals eligible to opt-in to the
CJR model that elect to participate in the
model, CMS intends to provide a
template that can be completed and
submitted prior to the proposed January
31, 2018 submission deadline. As stated
previously, we estimate that the number
of hospitals that will elect voluntary
participation in CJR is 60 to 80. As
stated previously, this template would
be designed to minimize burden on
participants, particularly since all
necessary information required to
effectively opt-in will be included
within the template. Using wage
information from the Bureau of Labor
Statistics for medical and health service
managers (Code 11–9111), we assumed
a rate of $105.16 per hour, including
overhead and fringe benefits (https://
www.bls.gov/oes/current/oes_nat.htm)
and estimated that the time to complete
the opt-in template would be, on
average, approximately 30 minutes per
hospital. Thus, total costs associated
with completing opt-in templates for all
60 to 80 hospitals projected to elect
voluntary participation is expected to
range between $3,150 (60 hospitals) and
$4,200 (80 hospitals).
We seek comment on our assumptions
and information on any costs associated
with this work.
H. Regulatory Review Costs
If regulations impose administrative
costs on private entities, such as the
time needed to read and interpret this
proposed rule, we should estimate the
cost associated with regulatory review.
Due to the uncertainty involved with
accurately quantifying the number of
entities that will review the rule, we
assume that the total number of unique
commenters on the EPM proposed rule
will be the number of reviewers of this
proposed rule. We acknowledge that
this assumption may understate or
overstate the costs of reviewing this
rule. It is possible that not all
commenters reviewed the precedent
rule in detail, and it is also possible that
some reviewers chose not to comment
on the proposed rule. For these reasons
we thought that the number of past
commenters on the EPM proposed rule
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would be a fair estimate of the number
of reviewers of this rule. We welcome
any comments on the approach in
estimating the number of entities that
would review this proposed rule.
We also recognize that different types
of entities are in many cases affected by
mutually exclusive sections of this
proposed rule, however for the purposes
of our estimate we assume that each
reviewer reads approximately 100
percent of the rule. We seek comments
on this assumption.
Using the wage information from the
BLS for medical and health service
managers (Code 11–9111), we estimate
that the cost of reviewing this rule is
$105.16 per hour, including overhead
and fringe benefits https://www.bls.gov/
oes/current/oes_nat.htm. Assuming an
average reading speed, we estimate that
it would take approximately 1.6 hours
for the staff to review this proposed
rule. For each entity that reviews the
rule, the estimated cost is $168.26 (1.6
hours × $105.16). Therefore, we estimate
that the total cost of reviewing this
regulation is $29,445 ($105.16 × 175
reviewers).
I. Unfunded Mandates
Section 202 of the Unfunded
Mandates Reform Act of 1995 (UMRA)
also requires that agencies assess
anticipated costs and benefits before
issuing any rule whose mandates
require spending in any 1 year of $100
million in 1995 dollars, updated
annually for inflation. In 2017, that is
approximately $148 million. This
proposed rule does not include any
mandate that would result in spending
by state, local or tribal governments, in
the aggregate, or by the private sector in
the amount of $148 million in any 1
year.
sradovich on DSK3GMQ082PROD with PROPOSALS2
J. Federalism
We do not believe that there is
anything in this proposed rule that
either explicitly or implicitly preempts
any state law, and furthermore we do
not believe that this proposed rule
would have a substantial direct effect on
state or local governments, preempt
state law, or otherwise have a federalism
implication.
K. Reducing Regulation and Controlling
Regulatory Costs
Executive Order 13771, titled
Reducing Regulation and Controlling
Regulatory Costs (82 FR 9339), was
issued on January 30, 2017. This
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proposed rule, if finalized as proposed,
is not expected to be subject to the
requirements of E.O. 13771 because it is
estimated to result in no more than de
minimis costs.
L. Alternatives Considered
Throughout this proposed rule, we
have identified our proposed policies
and alternatives that we have
considered, and provided information
as to the effects of these alternatives and
the rationale for each of the proposed
policies. We considered but did not
propose to allow voluntary participation
in all of the 67 selected MSAs in the CJR
model because the overall estimated CJR
model impact would no longer show
savings, and would likely result in
costs. An entirely voluntary CJR model
would likely result in costs due to the
assumption that, in aggregate, hospitals
that expect to receive a positive
reconciliation payment from Medicare
would elect to opt-in to the model while
hospitals that expect to owe Medicare a
reconciliation amount would not likely
elect to participate in the model. We
also considered but did not propose
limiting participation to the proposed
34 mandatory participation MSAs and
not allowing voluntary participation in
any of the 67 selected MSAs. If
participation was limited to the
proposed 34 mandatory participation
MSAs and voluntary participation was
not allowed in any MSA, the impact to
the overall estimated model savings
over the last three years of the model
would be closer to $30 million than the
$90 million estimate presented in
section V. of this proposed rule, because
our modeling does not include
assumptions about behavioral changes
that might lower fee-for-service
spending. Since our impact model
estimates that 60 to 80 hospitals would
choose voluntary participation and that
these potential voluntary participants
would be expected to earn only positive
reconciliation payments under the
model, these positive payments to the
voluntary participants would offset
some of the savings garnered from
mandatory participants. However, we
are proposing to allow voluntary
participation in the proposed 33
voluntary participation MSAs and for
low-volume and rural hospitals to
permit hospitals that have made
investments in care redesign and
commitments to improvement to
continue to participate in the model for
the remaining 3 years. We believe our
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proposal would benefit a greater number
of beneficiaries because a greater
number of hospitals would be included
in the CJR model.
Instead of proposing to cancel the
EPMs and CR incentive payment model,
we considered altering the design of
these models to allow for voluntary
participation but as this would
potentially involve restructuring the
model design, payment methodologies,
financial arrangement provisions and/or
quality measures, we did not believe
that such alterations would offer
providers enough time to prepare for
such changes, given the planned
January 1, 2018 start date. In addition,
if at a later date we decide to offer these
models, or similar models, on a
voluntary basis, we would not expect to
implement them through rulemaking,
but rather would establish them
consistent with the manner in which we
have implemented other voluntary
models.
We solicit and welcome comments on
our proposals, on the alternatives we
have identified, and on other
alternatives that we should consider, as
well as on the costs, benefits, or other
effects of these.
M. Accounting Statement and Table
As required by OMB Circular A–4
under Executive Order 12866 (available
at https://www.whitehouse.gov/omb/
circulars_a004_a-4) in Table 7, we have
prepared an accounting statement
showing the classification of transfers
associated with the provisions in this
proposed rule. The accounting
statement is based on estimates
provided in this regulatory impact
analysis. As described in Table 6, we
estimate the proposed changes to the
CJR model would continue to result in
savings to the federal government of
approximately $204 million over the 3
remaining performance years of the
model from 2018 to 2020, noting these
changes do reduce the original CJR
estimated savings by approximately $90
million. In Table 7, the overall
annualized change in payments (for all
provisions in this proposed rule relative
to the CJR model as originally finalized)
based on a 7-percent and 3-percent
discount rate, results in net federal
monetary transfer from the federal
government to participant IPPS
hospitals of $73.2 million and $82.4
million in 2017 dollars, respectively,
over the period of 2018 to 2020.
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TABLE 7—ACCOUNTING STATEMENT CHANGES TO COMPREHENSIVE CARE FOR JOINT REPLACEMENT MODEL FOR
PERFORMANCE YEARS 2018 TO 2020
Units
Category
Estimates
Year dollar
Costs: *
Upfront cost of regulation ($million) .............................................
From Whom to Whom
0.03
0.03
Discount rate
(%)
2017
2017
7
3
Period covered
2018 upfront cost.
2018 upfront cost.
Incurred by IPPS Hospitals as a result of this regulation.
Transfers:
Annualized/Monetized ($million/year) ...........................................
From Whom To Whom
27.90
29.14
2017
2017
7
3
2018–2020.
2018–2020.
From the Federal Government to Participating IPPS Hospitals.
* The cost includes the regulatory familiarization and completing opt-in templates for up to 80 hospitals to join the CJR model.
M. Conclusion
This analysis, together with the
remainder of this preamble, provides
the Regulatory Impact Analysis of a
rule. As a result of this proposed rule,
we estimate that the financial impact of
the changes to the CJR model proposed
here would result in a reduction to
previously estimated savings by $90
million over the 3 remaining
performance years (2018 through 2020)
although we note that the CJR model
would still be estimated to save the
Medicare program approximately $204
million over the remaining three
performance years.
In accordance with the provisions of
Executive Order 12866, this rule was
reviewed by the Office of Management
and Budget.
VI. Response to Comments
Because of the large number of public
comments we normally receive on
Federal Register documents, we are not
able to acknowledge or respond to them
individually. We will consider all
comments we receive by the date and
time specified in the DATES section of
this preamble, and, when we proceed
with a subsequent document, we will
respond to the comments in the
preamble to that document.
sradovich on DSK3GMQ082PROD with PROPOSALS2
List of Subjects
42 CFR Part 510
Administrative Practice and
Procedure, Health facilities, Health
professions, Medicare, and Reporting
and recordkeeping requirements.
42 CFR Part 512
Administrative Practice and
Procedure, Health facilities, Health
professions, Medicare, and Reporting
and recordkeeping requirements.
For the reasons set forth in the
preamble, under the authority at section
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1115A of the Social Security Act, the
Centers for Medicare & Medicaid
Services proposes to amend 42 CFR
Chapter IV, as follows:
PART 510—COMPREHENSIVE CARE
FOR JOINT REPLACEMENT MODEL
1. The authority citation for part 510
continues to read as follows:
■
Authority: Secs. 1102, 1115A, and 1871 of
the Social Security Act (42 U.S.C. 1302,
1315(a), and 1395hh).
2. Section 510.2 is amended by—
a. Revising the definition of ‘‘Actual
episode payment’’;
■ b. Adding, in alphabetical order,
definitions of ‘‘Low-volume hospital’’
and ‘‘mandatory MSA’’.
■ c. Revising the definition of
‘‘participant hospital’’; and
■ d. Adding the definition of ‘‘voluntary
MSA’’.
The revisions and additions read as
follows:
■
■
§ 510.2
Definitions.
*
*
*
*
*
Actual episode payment means the
sum of standardized Medicare claims
payments for the items and services that
are included in the episode in
accordance with § 510.200(b), excluding
the items and services described in
§ 510.200(d).
*
*
*
*
*
Low-volume hospital means a hospital
identified by CMS as having fewer than
20 LEJR episodes in total across the 3
historical years of data used to calculate
the performance year 1 CJR episode
target prices.
*
*
*
*
*
Mandatory MSA means an MSA
designated by CMS as a mandatory
participation MSA in accordance with
§ 510.105(a).
*
*
*
*
*
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Participant hospital means one of the
following:
(1) During performance years 1 and 2
of the CJR model and the period from
January 1, 2018 to January 31, 2018 of
performance year 3, a hospital (other
than a hospital excepted under
§ 510.100(b)) with a CCN primary
address located in one of the geographic
areas selected for participation in the
CJR model in accordance with
§ 510.105.
(2) Beginning February 1, 2018, a
hospital (other than a hospital excepted
under § 510.100(b)) that is one of the
following:
(i) A hospital with a CCN primary
address located in a mandatory MSA as
of February 1, 2018 that is not a rural
hospital or a low-volume hospital on
that date.
(ii) A hospital that is a rural hospital
or low-volume hospital with a CCN
primary address located in a mandatory
MSA that makes an election to
participate in the CJR model in
accordance with § 510.115.
(iii) A hospital with a CCN primary
address located in a voluntary MSA that
makes an election to participate in the
CJR model in accordance with
§ 510.115.
*
*
*
*
*
Voluntary MSA means an MSA
designated by CMS as a voluntary
participation MSA in accordance with
§ 510.105(a).
■ 3. Section 510.105 is amended by
revising paragraph (a) to read as follows:
§ 510.105
Geographic areas.
(a) General. The geographic areas for
inclusion in the CJR model are obtained
based on a stratified random sampling
of certain MSAs in the United States.
(1) All counties within each of the
selected MSAs are selected for inclusion
in the CJR model.
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(2) Beginning with performance year
3, the selected MSAs are designated as
either mandatory participation MSAs or
voluntary participation MSAs.
*
*
*
*
*
■ 4. Section 510.115 is added to read as
follows:
sradovich on DSK3GMQ082PROD with PROPOSALS2
§ 510.115
Voluntary participation election.
(a) General. To continue participation
in performance year 3 and participate in
performance year 4 and performance
year 5, the following hospitals must
submit a written participation election
letter as described in paragraph (c) of
this section during the voluntary
participation election period specified
in paragraph (b) of this section:
(1) Hospitals (other than those
excluded under § 510.100(b)) with a
CCN primary address in a voluntary
MSA.
(2) Low-volume hospitals with a CCN
primary address in a mandatory MSA.
(3) Rural hospitals with a CCN
primary address in a mandatory MSA.
(b) Voluntary participation election
period. The voluntary participation
election period begins on January 1,
2018 and ends on January 31, 2018.
(c) Voluntary participation election
letter. The voluntary participation
election letter serves as the model
participation agreement. CMS accepts
the voluntary participation election
letter if the letter meets all of the
following criteria:
(1) Includes the following:
(i) Hospital name.
(ii) Hospital address.
(iii) Hospital CCN.
(iv) Hospital contact name, telephone
number, and email address.
(v) Model name (that is, CJR model).
(vi) Attestation of CEHRT use as
specified in § 510.120(a)(1) (if the
hospital is choosing to participate in the
Advanced APM track).
(2) Includes a certification that the
hospital will—
(i) Comply with all applicable
requirements of this part and all other
laws and regulations applicable to its
participation in the CJR model; and
(ii) Submit data or information to
CMS that is accurate, complete and
truthful, including, but not limited to,
the participation election letter and any
quality data or other information that
CMS uses in its reconciliation
processes.
(3) Is signed by the hospital
administrator, CFO or CEO.
(4) Is submitted in the form and
manner specified by CMS.
■ 5. Section 510.120, as added January
3, 2017 (82 FR 180), delayed until
October 1, 2017, on March 21, 2017 (82
FR 14464), further delayed until January
VerDate Sep<11>2014
19:57 Aug 16, 2017
Jkt 241001
1, 2018, on May 19, 2017 (82 FR 22895),
is amended by removing paragraph
(b)(4), revising paragraph (c), and
adding paragraphs (d) and (e).
The revision and additions read as
follows:
§ 510.120 CJR participant hospital CEHRT
track requirements.
*
*
*
*
*
(c) Clinician engagement list. Each
participant hospital that chooses CEHRT
use as provided in paragraph (a)(1) of
this section must submit to CMS a
clinician engagement list in a form and
manner specified by CMS on a no more
than quarterly basis. This list must
include the following information on
individuals for the period of the
performance year specified by CMS:
(1) For each physician, nonphysician
practitioner, or therapist who is not a
CJR collaborator during the period of the
CJR model performance year specified
by CMS but who does have a
contractual relationship with the
participant hospital based at least in
part on supporting the participant
hospital’s quality or cost goals under the
CJR model during the period of the
performance year specified by CMS:
(i) The name, TIN, and NPI of the
individual.
(ii) The start date and, if applicable,
the end date for the contractual
relationship between the individual and
participant hospital.
(2) [Reserved]
(d) Attestation to no individuals. If
there are no individuals that meet the
requirements to be reported, as specified
in paragraphs (b)(1) through (3) or
paragraph (c) of this section, the
participant hospital must attest in a
form and manner required by CMS that
there are no individuals to report.
(e) Documentation requirements. (1)
Each participant hospital that chooses
CEHRT use as provided in paragraph
(a)(1) of this section must maintain
documentation of their attestation to
CEHRT use, clinician financial
arrangements lists, and clinician
engagement lists.
(2) The participant hospital must
retain and provide access to the
required documentation in accordance
with § 510.110.
■ 6. Section 510.210 is amended by
revising paragraph (b) to read as follows:
§ 510.210
Determination of the episode.
*
*
*
*
*
(b) Cancellation of an episode. The
episode is canceled and is not included
in the determination of NPRA as
specified in § 510.305 if any of the
following occur:
(1) The beneficiary does any of the
following during the episode:
PO 00000
Frm 00024
Fmt 4701
Sfmt 4702
(i) Ceases to meet any criterion listed
in § 510.205.
(ii) Is readmitted to any participant
hospital for another anchor
hospitalization.
(iii) Initiates an LEJR episode under
BPCI.
(iv) Dies.
(2) For performance year 3, the
participant hospital did not submit a
participation election letter that was
accepted by CMS to continue
participation in the model.
■ 7. Section 510.300 is amended by
revising paragraph (b)(6) to read as
follows:
§ 510.300 Determination of qualityadjusted episode target prices.
*
*
*
*
*
(b) * * *
(6) Exclusion of incentive programs
and add-on payments under existing
Medicare payment systems. Certain
incentive programs and add-on
payments are excluded from historical
episode payments by using, with certain
modifications, the CMS Price (Payment)
Standardization Detailed Methodology
used for the Medicare spending per
beneficiary measure in the Hospital
Value-Based Purchasing Program.
*
*
*
*
*
■ 8. Section 510.305 is amended by
revising paragraph (d)(1) to read as
follows:
§ 510.305 Determination of the NPRA and
reconciliation process.
*
*
*
*
*
(d) * * *
(1) Beginning 2 months after the end
of each performance year, CMS does all
of the following:
(i) Performs a reconciliation
calculation to establish an NPRA for
each participant hospital.
(ii) For participant hospitals that
experience a reorganization event in
which one or more hospitals reorganize
under the CCN of a participant hospital
performs—
(A) Separate reconciliation
calculations (during both initial and
subsequent reconciliations for a
performance year) for each predecessor
participant hospital for episodes where
anchor hospitalization admission
occurred before the effective date of the
reorganization event; and
(B) Reconciliation calculations
(during both initial and subsequent
reconciliations for a performance year)
for each new or surviving participant
hospital for episodes where the anchor
hospitalization admission occurred on
or after the effective date of the
reorganization event.
*
*
*
*
*
E:\FR\FM\17AUP2.SGM
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Federal Register / Vol. 82, No. 158 / Thursday, August 17, 2017 / Proposed Rules
9. Section 510.410 is amended by
adding paragraph (b)(1)(i)(G) to read as
follows:
■
§ 510.410
Compliance enforcement.
*
*
*
*
(b) * * *
(1) * * *
(i) * * *
(G) Failing to participate in CJR
model-related evaluation activities
conducted by CMS or its contractors or
both.
*
*
*
*
*
■ 10. Section 510.605 is amended by
revising paragraph (c)(2) to read as
follows:
sradovich on DSK3GMQ082PROD with PROPOSALS2
*
VerDate Sep<11>2014
19:57 Aug 16, 2017
Jkt 241001
§ 510.65 Waiver of certain telehealth
requirements.
*
*
*
*
*
(c) * * *
(2) CMS waives the payment
requirements under section
1834(m)(2)(B) of the Act to allow the
distant site payment for telehealth home
visit HCPCS codes unique to this model.
*
*
*
*
*
PART 512—[REMOVED AND
RESERVED]
PO 00000
Frm 00025
Fmt 4701
Sfmt 9990
further delayed until January 1, 2018, on
May 19, 2017 (82 FR 22895), is removed
and reserved.
Dated: August 10, 2017.
Seema Verma,
Administrator, Centers for Medicare &
Medicaid Services.
Dated: August 11, 2017.
Thomas E. Price,
Secretary, Department of Health and Human
Services.
[FR Doc. 2017–17446 Filed 8–15–17; 4:15 pm]
11. Part 512, as added January 3, 2017
(82 FR 180), delayed until October 1,
2017, on March 21, 2017 (82 FR 14464),
■
39333
BILLING CODE 4120–01–P
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Agencies
[Federal Register Volume 82, Number 158 (Thursday, August 17, 2017)]
[Proposed Rules]
[Pages 39310-39333]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2017-17446]
[[Page 39309]]
Vol. 82
Thursday,
No. 158
August 17, 2017
Part IV
Department of Health and Human Services
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Centers for Medicare & Medicaid Services
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42 CFR Parts 510 and 512
Medicare Program; Cancellation of Advancing Care Coordination Through
Episode Payment and Cardiac Rehabilitation Incentive Payment Models;
Changes to Comprehensive Care for Joint Replacement Payment Model (CMS-
5524-P); Proposed Rule
Federal Register / Vol. 82 , No. 158 / Thursday, August 17, 2017 /
Proposed Rules
[[Page 39310]]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
42 CFR Parts 510 and 512
[CMS-5524-P]
RIN 0938-AT16
Medicare Program; Cancellation of Advancing Care Coordination
Through Episode Payment and Cardiac Rehabilitation Incentive Payment
Models; Changes to Comprehensive Care for Joint Replacement Payment
Model (CMS-5524-P)
AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
ACTION: Proposed rule.
-----------------------------------------------------------------------
SUMMARY: This proposed rule proposes to cancel the Episode Payment
Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model
and to rescind the regulations governing these models. It also proposes
to revise certain aspects of the Comprehensive Care for Joint
Replacement (CJR) model, including: Giving certain hospitals selected
for participation in the CJR model a one-time option to choose whether
to continue their participation in the model; technical refinements and
clarifications for certain payment, reconciliation and quality
provisions; and a change to increase the pool of eligible clinicians
that qualify as affiliated practitioners under the Advanced Alternative
Payment Model (APM) track.
DATES: Comment period: To be assured consideration, comments on this
proposed rule must be received at one of the addresses provided in the
ADDRESSES section no later than 5 p.m. EDT on October 16, 2017.
ADDRESSES: In commenting, please refer to file code CMS-5524-P. Because
of staff and resource limitations, we cannot accept comments by
facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one
of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to https://www.regulations.gov. Follow the ``Submit a
comment'' instructions.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-5524-P, P.O. Box 8013,
Baltimore, MD 21244-1850.Please allow sufficient time for mailed
comments to be received before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-5524-P, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. Alternatively, you may deliver (by hand or
courier) your written comments ONLY to the following addresses prior to
the close of the comment period:
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue SW., Washington, DC
20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850. If you intend to deliver your
comments to the Baltimore address, call telephone number (410) 786-7195
in advance to schedule your arrival with one of our staff members.
Comments erroneously mailed to the addresses indicated as
appropriate for hand or courier delivery may be delayed and received
after the comment period.
For information on viewing public comments, see the beginning of
the SUPPLEMENTARY INFORMATION section.
FOR FURTHER INFORMATION CONTACT:
For questions related to the CJR model: CJR@cms.hhs.gov.
For questions related to the EPMs: EPMRULE@cms.hhs.gov.
SUPPLEMENTARY INFORMATION:
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: https://www.regulations.gov. Follow the search instructions on that Web site to
view public comments.
Comments received prior to the submission deadline will also be
available for public inspection as they are received, generally
beginning approximately three weeks after publication of a document, at
the headquarters of the Centers for Medicare & Medicaid Services, 7500
Security Boulevard, Baltimore, Maryland 21244, Monday through Friday of
each week from 8:30 a.m. to 4 p.m. To schedule an appointment to view
public comments, phone 1-800-743-3951.
Electronic Access
This Federal Register document is also available from the Federal
Register online database through Federal Digital System (FDsys), a
service of the U.S. Government Printing Office. This database can be
accessed via the internet at https://www.gpo.gov/fdsys/.
Acronyms
ACE Acute Care Episode Demonstration
ACO Accountable Care Organization
AMI Acute Myocardial Infarction
APM Alternative Payment Model
BPCI Bundled Payments for Care Improvement
CABG Coronary Artery Bypass Graft
CCN CMS Certification Number
CCSQ Center for Clinical Standards and Quality
CEHRT Certified Electronic Health Record Technology
CEO Chief Executive Officer
CFO Chief Financial Officer
CJR Comprehensive Care for Joint Replacement
CMS Centers for Medicare & Medicaid Services
CR Cardiac rehabilitation
CY Calendar Year
E/M Evaluation and Management
EPM Episode payment model
FFS Fee-for-service
FR Federal Register
HACRP Hospital-Acquired Condition Reduction Program
HHS U.S. Department of Health and Human Services
HVBP Hospital Value-Based Purchasing Program
ICD-CM International Classification of Diseases, Clinical
Modification
IFC Interim Final Rule with Comment Period
IPPS Inpatient Prospective Payment System
LEJR Lower-extremity joint replacement
MPFS Medicare Physician Fee Schedule
MP Malpractice
MSA Metropolitan Statistical Area
MS-DRG Medical Severity Diagnosis-Related Group
NPI National Provider Identifier
NPRA Net Payment Reconciliation Amount
NQF National Quality Forum
OMB Office of Management and Budget
PE Practice Expense
PGP Physician Group Practice
[[Page 39311]]
PRO Patient-Reported Outcome
PY Performance year
QP Qualifying APM Participant
RFA Regulatory Flexibility Act
RSCR Risk-Standardized Complication Rate
RVU Relative Value Unit
SHFFT Surgical hip/femur fracture treatment
THA Total hip arthroplasty
TIN Taxpayer Identification Number
TKA Total knee arthroplasty
UMRA Unfunded Mandates Reform Act
I. Executive Summary
A. Purpose
The purpose of this proposed rule is to propose to cancel the
Episode Payment Models (EPMs) and the Cardiac Rehabilitation (CR)
incentive payment model, established by the Center for Medicare and
Medicaid Innovation (Innovation Center) under the authority of section
1115A of the Social Security Act (the Act), and to rescind the
regulations at 42 CFR part 512. Additionally, this proposed rule
proposes to prospectively make participation voluntary for all
hospitals in approximately half of the geographic areas selected for
participation in the Comprehensive Care for Joint Replacement (CJR)
model (that is, in 33 of the 67 Metropolitan Statistical Areas (MSAs)
selected; (see 80 FR 73299 Table 4)) and for low-volume and rural
hospitals in all of the geographic areas selected for participation in
the CJR model. We are also proposing several technical refinements and
clarifications for certain CJR model payment, reconciliation, and
quality provisions, and a change to the criteria for the Affiliated
Practitioner List to broaden the CJR Advanced Alternative Payment Model
(APM) track to additional eligible clinicians.
We note that review and reevaluation of policies and programs, as
well as revised rulemaking, are within an agency's discretion, and that
discretion is often exercised after a change in administration occurs.
The EPMs and the CR incentive models were designed as mandatory payment
models and implemented via notice and comment rulemaking to test the
effects of bundling cardiac and orthopedic care beginning in 2018 and
further incentivizing higher value care. The CJR model was also
designed as a mandatory payment model established via notice and
comment rulemaking to test the effects of bundling on orthopedic
episodes involving lower extremity joint replacements; we note that the
CJR model began on April 1, 2016 and is currently in its second
performance year.
While we continue to believe that cardiac and orthopedic episode
models offer opportunities to redesign care processes and improve
quality and care coordination across the inpatient and post-acute care
spectrum while lowering spending, after careful review, we have
determined that it is appropriate to propose to rescind the regulations
at 42 CFR part 512, which relate to the EPMs and CR incentive payment
model, and reduce the geographic scope of the CJR model for the
following reasons. First, we believe that requiring hospitals to
participate in additional episode payment models at this time is not in
the best interest of the agency or the affected providers. Many
providers are currently engaged in voluntary initiatives with CMS, and
we expect to continue to offer opportunities for providers to
participate in voluntary initiatives, including episode-based payment
models. We are concerned that engaging in large mandatory episode
payment model efforts at this time may impede our ability to engage
providers, such as hospitals, in future voluntary efforts. Similarly,
we also believe that reducing the number of providers required to
participate in the CJR model will allow us to continue to evaluate the
effects of such a model while limiting the geographic reach of our
current mandatory models. We considered altering the design of the EPMs
and the CR incentive payment model to allow for voluntary participation
and to take into account other feedback on the models, but as this
would potentially involve restructuring the model design, payment
methodologies, financial arrangement provisions and/or quality
measures, we did not believe that such alterations would offer
providers enough time to prepare for such changes, given the planned
January 1, 2018 start date. In addition, if at a later date we decide
to test these models, or similar models, on a voluntary basis, we would
not expect to implement them through rulemaking, but rather would use
methods of soliciting applications and securing participants' agreement
to participate consistent with how we have implemented other voluntary
models. Finally, we believe that canceling the EPMs and CR incentive
payment model, as well as altering the scope of the CJR model, offers
CMS greater flexibility to design and test other episode-based payment
models, while still allowing us to test and evaluate the impact of the
ongoing CJR model on enhancing the quality of care while reducing
costs. Hospitals in the CJR model have been participating for more than
a year and a half, and we have begun to give hospitals in the model
financial and quality results from the first performance year. In many
cases, CJR hospitals have made investments in care redesign, and we
want to recognize such investments and commitments to improvement while
reducing the overall number of hospitals that are required to
participate.
We seek public comment on the proposals contained in this proposed
rule, and also on any alternatives considered.
B. Summary of Economic Effects
We do not anticipate that our proposal to cancel the EPMs and CR
incentive payment model prior to the start of those models will have
any costs to providers. As shown in our impact analysis in section V.
of this proposed rule, we estimate that the CJR model changes we are
proposing will reduce the previously projected CJR model savings (82 FR
603) by approximately $90 million. Therefore, we estimate that the
total CJR model impact after the changes in this proposed rule will
save the Medicare program $204 million, instead of $294 million, over
the remaining 3-year performance period (2018 through 2020) of the CJR
model. Our impact analysis has some degree of uncertainty and makes
assumptions as discussed in section V. of this proposed rule. In
addition to these estimated impacts, as with many of the Innovation
Center models, the goals that participants are attempting to achieve
include improving overall quality of care, enhancing participating
provider infrastructure to support better care management and reducing
costs. We anticipate there will continue to be a broader focus on care
coordination and quality improvement through the CJR model among
hospitals and other providers and suppliers within the Medicare program
that may lead to better care management and improved quality of care
for beneficiaries.
II. Statutory Authority and Background
Under the authority of section 1115A of the Social Security Act
(the Act), through notice-and-comment rulemaking, CMS' Center for
Medicare and Medicaid Innovation (Innovation Center) established the
Comprehensive Care for Joint Replacement model in a final rule titled
``Medicare Program; Comprehensive Care for Joint Replacement Payment
Model for Acute Care Hospitals Furnishing Lower Extremity Joint
Replacement Services'' published in the November 24, 2015 Federal
Register (80 FR 73274 through 73554) (referred to in this proposed rule
as the ``CJR model final rule''). We established three new models for
acute myocardial infarction, coronary artery
[[Page 39312]]
bypass graft, and surgical hip/femur fracture treatment episodes of
care, which are collectively called the Episode Payment Models (EPMs),
created a Cardiac Rehabilitation incentive payment model (CR incentive
payment model), and revised several existing provisions for the CJR
model, in a final rule titled ``Advancing Care Coordination Through
Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment
Model; and Changes to the Comprehensive Care for Joint Replacement
Model'' published in the January 3, 2017 Federal Register (82 FR 180)
(referred to in this proposed rule as the ``EPM final rule'').
The effective date for most of the provisions of the EPM final rule
was February 18, 2017, and in the EPM final rule we specified an
effective date of July 1, 2017 for certain CJR model regulatory changes
intended to align with a July 1, 2017 applicability, or start, date for
the EPMs and CR incentive payment model. On January 20, 2017, the
Assistant to the President and Chief of Staff issued a memorandum
titled ``Regulatory Freeze Pending Review'' that instructed Federal
agencies to temporarily postpone the effective date for 60 days from
the date of the memorandum for regulations that had been published in
the Federal Register but had not taken effect, for purposes of
reviewing the rules and considering potentially proposing further
notice-and-comment rulemaking. Accordingly, on February 17, 2017, we
issued a final rule in the Federal Register (82 FR 10961) to delay
until March 21, 2017 the effective date of any provisions of the EPM
final rule that were to become effective on February 18, 2017. We
subsequently issued an interim final rule with comment (IFC) period in
the Federal Register on March 21, 2017 (referred to in this proposed
rule as the ``March 21, 2017 IFC'') (82 FR 14464). The March 21, 2017
IFC further delayed the effective date of the provisions that were to
take effect March 21, 2017 until May 20, 2017, further delayed the
applicability date of the EPMs and CR incentive payment model
provisions until October 1, 2017, and further delayed the effective
date of the conforming CJR model changes until October 1, 2017. In the
March 21, 2017 IFC, we also solicited public comment on further
delaying the applicability date for the EPMs and CR incentive payment
provisions, as well as the effective date for the conforming changes to
the CJR model from October 1, 2017 until January 1, 2018 to allow for
additional notice-and-comment rulemaking. Based on the public comments
we received in response to the March 21, 2017 IFC, we published a final
rule (referred to in this proposed rule as the ``May 19, 2017 final
delay rule'') on May 19, 2017 (82 FR 22895) to finalize a January 1,
2018 applicability date for the EPMs and CR incentive payment
provisions, as well as to finalize a January 1, 2018 effective date for
the conforming changes to the CJR model (specifically amending Sec.
510.2; adding Sec. 510.110; amending Sec. 510.120; amending Sec.
510.405; amending Sec. 510.410; revising Sec. 510.500; revising Sec.
510.505; adding Sec. 510.506; and amending Sec. 510.515). Additional
changes to the CJR model, in accordance with the March 21, 2017 IFC,
took effect May 20, 2017.
As we stated in the May 19, 2017 final delay rule (82 FR 22897), we
received a number of comments on the models that did not relate to the
start date change comment solicitation. These additional comments
suggested that we reconsider or revise various model aspects, policies
and design components; in particular, many of these comments suggested
that we should make participation in the models voluntary instead of
mandatory. We did not respond to these comments in the May 19, 2017
final delay rule, as the comments were out of scope of that rulemaking,
but we stated that we might take them into consideration in future
rulemaking.
Our specific proposals are discussed in the following sections of
this proposed rule.
III. Provisions of the Proposed Regulations
A. Proposed Cancellation of EPMs and Cardiac Rehabilitation Incentive
Payment Model
In the January 3, 2017 EPM final rule, we established three bundled
payment models for acute myocardial infarction (AMI), coronary artery
bypass graft (CABG), and surgical hip/femur fracture treatment (SHFFT)
episodes, and a Cardiac Rehabilitation (CR) incentive payment model.
These models are similar to other Innovation Center models and focus on
more complex cases where we believe improvements in care coordination
and other care redesign efforts offer the potential for improved
patient outcomes and more efficient use of resources. Many
stakeholders, including commenters responding to the March 21, 2017
IFC, have expressed concerns about the provider burden and challenges
these new models present. As we noted in the May 19, 2017 final delay
rule (82 FR 22896), which finalized a January 1, 2018 start date for
the EPMs and the CR incentive payment model, we would engage in notice
and comment rulemaking on these models if we believed it to be
warranted. We also noted that we received 47 submissions in response to
the March 21, 2017 IFC. These responses contained a mix of in- and out-
of-scope comments (82 FR 22899). In the May 19, 2017 final delay rule
(82 FR 22897), we noted that in addition to commenting on the change to
the effective date for the EPMs and CR incentive payment model and
certain provisions of the CJR model, commenters highlighted concerns
with the models' design, including but not limited to participation
requirements, data, pricing, quality measures, episode length, CR and
skilled nursing facility (SNF) waivers, beneficiary exclusions and
notification requirements, repayment, coding, and model overlap issues.
Specifically, many commenters were opposed to the mandatory
participation requirements, arguing that the mandatory nature of these
models would force many providers who lack familiarity, experience, or
proper infrastructure to quickly support care redesign efforts for a
new bundled payment system. Many commenters were concerned that the
mandatory nature of these models might harm patients and providers
before CMS knows how these models might affect access to care, quality
or outcomes in various locations. Additionally, commenters were
concerned that unrelated services would be incorporated into episode
prices under the finalized price setting methodology, which bases
prices on MS-DRGs and identifies excluded, unrelated services rather
than included, related services based on clinical review. Commenters
also expressed concern that this pricing approach would result in
diagnosis codes that would be classified as included services, when in
fact these services have no clinical relevance to the episode(s).
Commenters were further concerned with the fact that CMS will
progressively incorporate regional data into EPM target prices, where
100 percent of the EPM target price would be based on regional data by
performance year 4. Commenters also took issue with the quality
measures established for the SHFFT model, stating that these measures
are not clinically related to the target population and are
inappropriate for use in assessing the care provided to beneficiaries
in the SHFFT model. In addition, commenters requested revisions to the
CABG EPM to allow participants the option to use a CABG
[[Page 39313]]
composite score developed by the Society of Thoracic Surgeons (STS)
rather than the all-cause mortality measure.
Commenters also expressed concerns about the design of the CR
incentive payment model waivers. Commenters stated that current direct
supervision requirements would continue to contribute to a lack of
access to cardiac rehabilitation services and would inhibit providers'
ability to redesign care for the CR incentive payment model. Commenters
suggested broadening the CR physician supervision waiver because the
current waivers would not cover non-model beneficiaries who might be
obtaining services concurrently with model participants and are
therefore not sufficient. Other commenters were concerned with the
precedence rules for model overlap with Models 2, 3 and 4 of the
Innovation Center's Bundled Payments for Care Improvement (BPCI)
initiative.
In the May 19, 2017 final delay rule (82 FR 22895), we stated that
we might consider these public comments in future rulemaking. Based on
our additional review and consideration of this stakeholder feedback,
we have concluded that certain aspects of the design of the EPMs and
the CR incentive payment model should be improved and more fully
developed prior to the start of the models, and that moving forward
with the implementation of the EPMs and CR incentive payment model as
put forth in the January 3, 2017 EPM final rule would not be in the
best interest of beneficiaries or providers at this time. Based on our
acknowledgment of the many concerns about the design of these models
articulated by stakeholders, we are proposing to cancel the EPMs and CR
incentive payment model before they begin. Accordingly, we propose to
rescind 42 CFR part 512 in its entirety.
We seek public comment on our proposal to cancel the EPMs and CR
incentive payment model.
We note that, if the proposal to cancel the EPMs and CR incentive
payment model is finalized, providers interested in participating in
bundled payment models may still have an opportunity to do so during
calendar year (CY) 2018 via new voluntary bundled payment models.
Building on the BPCI initiative, the Innovation Center expects to
develop new voluntary bundled payment model(s) during CY 2018 that
would be designed to meet the criteria to be an Advanced APM. We also
note the strong evidence base and other positive stakeholder feedback
that we have received regarding the CR incentive payment model. As we
further develop the Innovation Center's portfolio of models, we may
revisit this model and will consider stakeholder feedback for a
potential new voluntary initiative.
B. Proposed Changes to the CJR Model Participation Requirements
1. Proposed Voluntary Participation Election (Opt-In) for Certain MSAs
and Low-Volume and Rural Hospitals
The CJR model began on April 1, 2016. The CJR model is currently in
the second performance year, which includes episodes ending on or after
January 1, 2017 and on or before December 31, 2017. The third
performance year, which includes all CJR episodes ending on or after
January 1, 2018 and on or before December 31, 2018, would necessarily
incorporate episodes beginning before January 2018. The fifth, and
last, performance year would end on December 31, 2020. Currently, with
limited exceptions, hospitals located in the 67 geographic areas
selected for participation in the CJR model must participate in the
model through December 31, 2020; that is, their participation in the
CJR model is mandatory unless the hospital is an episode initiator for
a lower-extremity joint replacement (LEJR) episode in the risk-bearing
period of Models 2 or 4 of the BPCI initiative. Hospitals with a CCN
primary address in the 67 selected geographic areas that participated
in Model 1 of the BPCI initiative, which ended on December 31, 2016,
began participating in the CJR model when their participation in the
BPCI initiative ended.
Based on smaller, voluntary tests of episode-based payment models
and demonstrations, such as the Acute Care Episode (ACE) demonstration
and the BPCI initiative, that have indicated a potential to improve
beneficiaries' care while reducing costs (see ACE evaluation at:
https://downloads.cms.gov/files/cmmi/ace-evaluationreport-final-5-2-14.pdf and BPCI evaluation at: https://innovation.cms.gov/Files/reports/BPCI-EvalRpt1.pdf), we finalized the CJR model with mandatory
participation in the 67 selected geographic areas so that we could
further test delivery of better care at a lower cost across a wide
range of hospitals, including some hospitals that may not otherwise
participate, in many locations across the country. In the CJR model
final rule (80 FR 73276), we stated that we believed that by requiring
the participation of a large number of hospitals with diverse
characteristics, the CJR model would result in a robust data set for
evaluation of this bundled payment approach, and would stimulate the
rapid development of new evidence-based knowledge. Testing the model in
this manner would also allow us to learn more about patterns of
inefficient utilization of health care services and how to incentivize
the improvement of quality for common LEJR procedure episodes.
After further consideration of stakeholder feedback, including
responses we received on the March 21, 2017 IFC, we are proposing
certain revisions to the mandatory participation requirements for the
CJR model to allow us to continue to evaluate the effects of the model
while limiting the geographic reach of our current mandatory models.
Specifically, we are proposing that the CJR model would continue on a
mandatory basis in approximately half of the selected geographic areas
(that is, 34 of the 67 selected geographic areas), with an exception
for low-volume and rural hospitals, and continue on a voluntary basis
in the other areas (that is, 33 of the 67 selected geographic areas).
The geographic areas for the CJR model are certain Metropolitan
Statistical Areas (MSAs) that were selected following the requirements
in Sec. 510.105 as discussed in the CJR model final rule (80 FR 73297
through 73299). In Sec. 510.2, an MSA is defined as a core-based
statistical area associated with at least one urbanized area that has a
population of at least 50,000. In selecting the 67 MSAs for inclusion
in the CJR model, the 196 eligible MSAs were stratified into 8 groups
based on MSA average wage adjusted historic LEJR episode payments and
MSA population size (80 FR 41207). Specifically, we classified MSAs
according to their average LEJR episode payment into four categories
based on the 25th, 50th and 75th percentiles of the distribution of the
196 potentially selectable MSAs as determined in the exclusion rules as
applied in the CJR model proposed rule (80 FR 41198). This approach
ranked the MSAs relative to one another and created four equally sized
groups of 49. The population distribution was divided at the median
point for the MSAs eligible for potential selection, creating 8 groups.
Of the 196 eligible MSAs, we chose 67 MSAs via a stratified random
selection process as discussed in the CJR model final rule (80 FR
73291). In reviewing our discussion of the MSA selection and the MSA
volume needed to provide adequate statistical power to evaluate the
impact of the model in the CJR model final rule (80 FR 73297), we have
determined that reducing the mandatory MSA volume in half by selecting
the 34
[[Page 39314]]
MSAs with the highest average wage-adjusted historic LEJR episode
payments for continued mandatory participation could still allow us to
evaluate the effects of the CJR model across a wide range of providers,
including some that might not otherwise participate in the model.
Higher payment areas are most likely to have significant room for
improvement in creating efficiencies and greater variations in practice
patterns. Thus, the selection of more expensive MSAs is the most
appropriate approach to fulfilling the overall priorities of the CJR
model to increase efficiencies and savings for LEJR episodes while
maintaining or improving the overall quality of care.
The original determination of the sample size need in the CJR model
final rule was constructed to be able to observe a 2-percent reduction
in wage-adjusted episode spending after 1 year. This amount was chosen
based on the anticipated amount of the discount applied in the target
price. In considering the degree of certainty that would be needed to
generate reliable statistical estimates, we assumed a 20 percent chance
of false positive and a 30 percent chance of a false negative. Using
these parameters, we determined that the number of MSAs needed ranged
from 50 to 150. In order to allow for some degree of flexibility, we
selected 75 MSAs, which were narrowed to 67 due to final exclusion
criteria.
As we reviewed the CJR model for this proposed rule, we noted that,
excluding quarterly reconciliation amounts, evaluation results from
BPCI Model 2 have indicated possible reductions in fee-for-service
spending of approximately 3 percent on orthopedic surgery episodes for
hospitals participating in the LEJR episode bundle. (https://innovation.cms.gov/Files/reports/bpci-models2-4-yr2evalrpt.pdf). We
examined the sample size needed to detect a 3-percent reduction in CJR
model episode spending after 1 year using the same methodology as
described in the CJR model final rule. We determined that we would be
able to meet this standard with 34 MSAs from the higher cost groups. We
expect that hospitals in the higher cost MSAs will be able to achieve
similar 3 percent savings given their MSA's relatively high historic
episode spending and thus greater opportunities for improvements, and
their experience in optimizing clinical care pathways to produce
greater efficacies over the first two performance years of the CJR
model. We note that the proposed changes to the model, including the
focus on higher cost MSAs and the reduced number of mandatory MSAs,
will cause changes to the nature of the evaluation.
To select the 34 MSAs that would continue to have mandatory
participation (except for low-volume and rural hospitals), we took the
distribution of average wage-adjusted historic LEJR episode payments
for the 67 MSAs using the definition described in the CJR model final
rule, ordered them sequentially by average wage-adjusted historic LEJR
episode payments, and then selected the 34 MSAs with the highest
average payments. Under this proposal to reduce the number of MSAs with
mandatory participation, the remaining 33 MSAs would no longer be
subject to the CJR model's mandatory participation requirements; that
is, hospital participation would be voluntary in these 33 MSAs.
After dividing the 67 MSAs into 34 mandatory and 33 voluntary MSAs
as described previously, we examined selected MSA characteristics. In
order to determine whether a good balance was maintained across MSA
population size, we examined the number of MSAs below and above the
median population point of the 196 MSAs eligible for potential
selection. We observed that a good balance of MSA population size was
maintained (17 out of 34 mandatory and 17 out of 33 voluntary MSAs had
a population above the median population). While the 34 MSAs that would
continue to have mandatory participation have higher spending on
average, these MSAs all include providers with average cost episodes in
addition to providers with high cost episodes. In general, we note that
hospitals located in higher cost areas have a greater potential to
demonstrate significant decreases in episode spending. However, within
the higher cost MSAs, there is still significant variation in
characteristics and experiences of the included hospitals. We
anticipate the evaluation will be able to assess the generalizability
of the findings of the CJR model by examining variations of performance
within the participating hospitals who represent a wide range of
hospital and market characteristics. Therefore, we are proposing that
the CJR model would have 34 mandatory participation MSAs (identified in
Table 1) and 33 voluntary participation MSAs (identified in Table 2)
for performance years 3, 4, and 5.
Specifically, we are proposing that, unless an exclusion in Sec.
510.100(b) applies (that is, for certain hospitals that participate in
the BPCI initiative), participant hospitals in the proposed 34
mandatory participation MSAs that are not low-volume or rural (as
defined in Sec. 510.2 and discussed in the following paragraphs) would
continue to be required to participate in the CJR model. We are also
proposing that hospitals in the proposed 33 voluntary participation
MSAs and hospitals that are low-volume or rural (as defined in Sec.
510.2 and discussed in the following paragraphs) would have a one-time
opportunity to notify CMS, in the form and manner specified by CMS, of
their election to continue their participation in the CJR model on a
voluntary basis (opt-in) for performance years 3, 4, and 5. Hospitals
that choose to participate in the CJR model and make a participation
election that complies with proposed Sec. 510.115 would be subject to
all model requirements. Hospitals in the proposed 33 voluntary
participation MSAs and low-volume and rural hospitals (as defined in
Sec. 510.2 and discussed in the following paragraphs) that do not make
a participation election would be withdrawn from the CJR model as
described later in this section of this proposed rule.
We are proposing to exclude and automatically withdraw low-volume
hospitals in the proposed 34 mandatory participation MSAs, as
identified by CMS (see Table 3), from participation in the CJR model
effective February 1, 2018. Since some low-volume hospitals may want to
continue their participation in the CJR model, we are proposing to
allow low-volume hospitals to make a one-time, voluntary participation
election that complies with the proposed Sec. 510.115 in order for the
low-volume hospital to continues its participation in the CJR model. We
are proposing to define a low-volume hospital in Sec. 510.2 as a
hospital identified by CMS as having fewer than 20 LEJR episodes in
total across the 3 historical years of data used to calculate the
performance year 1 CJR episode target prices. Note that under this
definition, all hospitals listed in Table 3 would meet the definition
of a low-volume hospital, but this list would not be inclusive of all
hospitals that could be identified by CMS as a low-volume hospital. For
example, a new hospital (with a new CCN) that opens in a mandatory MSA
during the remaining years of the CJR model would not have any LEJR
episodes during the historical years of data used to calculate the
performance year 1 CJR episode target prices. Under our proposal, we
intend that any hospital with a new CCN that comes into existence after
the proposed voluntary participation election period would not be
required and/or eligible to join the CJR model. Note that our proposed
policy for new hospitals
[[Page 39315]]
would not be applicable in the case of a reorganization event where the
remaining entity is a hospital with a CCN that was participating in the
CJR model prior to the reorganization event; consistent with our
current policy, such hospital would continue participation in the CJR
model regardless of whether all predecessor hospitals were participant
hospitals prior to the reorganization event.
We are also proposing to exclude and automatically withdraw rural
hospitals from participation in the CJR model effective February 1,
2018. Since some rural hospitals may want to continue their
participation in the CJR model, we are proposing to allow rural
hospitals to make a one-time, voluntary participation election that
complies with the proposed Sec. 510.115 in order for the rural
hospital to continues its participation in the CJR model. Specifically,
we are proposing that rural hospitals (as defined in Sec. 510.2) with
a CCN primary address in the 34 mandatory participation MSAs would have
a one-time opportunity to opt-in to continue its participation in the
CJR model during the proposed voluntary participation election period.
We are proposing that a hospital's change in rural status after the end
of the voluntary participation election period would not change the
hospital's CJR model participation requirements. Specifically, we are
proposing that hospitals in the proposed 34 mandatory participation
MSAs that are neither low-volume or rural hospitals during the proposed
voluntary participation election period would be required to
participate in the CJR model for performance years 3, 4, and 5, and
that these hospitals would continue to be required to participate in
the CJR model even if they subsequently become a rural hospital.
Similarly, we are proposing that a rural hospital that makes a
voluntary participation election during the one-time opportunity would
be required to continue participating in the CJR model if that hospital
no longer meets the definition of rural hospital in Sec. 510.2. We are
proposing this approach so that CMS can identify the hospitals, by CCN,
that would participate in the model for the remainder of performance
year 3 and performance years 4 and 5 at the conclusion of the proposed
voluntary participation election period and so that there would be less
confusion about which hospitals are CJR model participants. We seek
comment on this proposal.
Table 1--CJR Mandatory Participation MSAs
------------------------------------------------------------------------
Wage-adjusted
episode
MSA MSA name payments (in
$)
------------------------------------------------------------------------
10420..................... Akron, OH................... $28,081
11700..................... Asheville, NC............... 27,617
12420..................... Austin-Round Rock, TX....... 28,960
13140..................... Beaumont-Port Arthur, TX.... 32,544
17140..................... Cincinnati, OH-KY-IN........ 28,074
18580..................... Corpus Christi, TX.......... 30,700
20020..................... Dothan, AL.................. 30,710
22500..................... Florence, SC................ 27,901
23540..................... Gainesville, FL............. 29,370
24780..................... Greenville, NC.............. 27,446
25420..................... Harrisburg-Carlisle, PA..... 28,360
26300..................... Hot Springs, AR............. 29,621
28660..................... Killeen-Temple, TX.......... 27,355
31080..................... Los Angeles-Long Beach- 28,219
Anaheim, CA.
31180..................... Lubbock, TX................. 29,524
32820..................... Memphis, TN-MS-AR........... 28,916
33100..................... Miami-Fort Lauderdale-West 33,072
Palm Beach, FL.
33740..................... Monroe, LA.................. 30,431
33860..................... Montgomery, AL.............. 30,817
35300..................... New Haven-Milford, CT....... 27,529
35380..................... New Orleans-Metairie, LA.... 29,562
35620..................... New York-Newark-Jersey City, 31,076
NY-NJ-PA.
36420..................... Oklahoma City, OK........... 27,267
36740..................... Orlando-Kissimmee-Sanford, 29,259
FL.
37860..................... Pensacola-Ferry Pass-Brent, 29,485
FL.
38300..................... Pittsburgh, PA.............. 30,886
38940..................... Port St. Lucie, FL.......... 30,423
39340..................... Provo-Orem, UT.............. 28,852
39740..................... Reading, PA................. 28,679
42680..................... Sebastian-Vero Beach, FL.... 28,015
45300..................... Tampa-St. Petersburg- 32,424
Clearwater, FL.
45780..................... Toledo, OH.................. 28,658
46220..................... Tuscaloosa, AL.............. 31,789
46340..................... Tyler, TX................... 30,955
------------------------------------------------------------------------
Table 2--CJR Voluntary Participation MSAs
------------------------------------------------------------------------
Wage-adjusted
episode
MSA MSA name payments (in
$)
------------------------------------------------------------------------
10740..................... Albuquerque, NM............. $25,892
12020..................... Athens-Clarke County, GA.... 25,394
[[Page 39316]]
13900..................... Bismarck, ND................ 22,479
14500..................... Boulder, CO................. 24,115
15380..................... Buffalo-Cheektowaga-Niagara 26,037
Falls, NY.
16020..................... Cape Girardeau, MO-IL....... 24,564
16180..................... Carson City, NV............. 26,128
16740..................... Charlotte-Concord-Gastonia, 26,736
NC-SC.
17860..................... Columbia, MO................ 25,558
19500..................... Decatur, IL................. 24,846
19740..................... Denver-Aurora-Lakewood, CO.. 26,119
20500..................... Durham-Chapel Hill, NC...... 25,151
22420..................... Flint, MI................... 24,807
23580..................... Gainesville, GA............. 23,009
26900..................... Indianapolis-Carmel- 25,841
Anderson, IN.
28140..................... Kansas City, MO-KS.......... 27,261
30700..................... Lincoln, NE................. 27,173
31540..................... Madison, WI................. 24,442
33340..................... Milwaukee-Waukesha-West 25,698
Allis, WI.
33700..................... Modesto, CA................. 24,819
34940..................... Naples-Immokalee-Marco 27,120
Island, FL.
34980..................... Nashville-Davidson- 26,880
Murfreesboro-Franklin, TN.
35980..................... Norwich-New London, CT...... 25,780
36260..................... Ogden-Clearfield, UT........ 25,472
38900..................... Portland-Vancouver- 22,604
Hillsboro, OR-WA.
40980..................... Saginaw, MI................. 25,488
41180..................... St. Louis, MO-IL............ 26,425
41860..................... San Francisco-Oakland- 23,716
Hayward, CA.
42660..................... Seattle-Tacoma-Bellevue, WA. 23,669
43780..................... South Bend-Mishawaka, IN-MI. 23,143
44420..................... Staunton-Waynesboro, VA..... 25,539
45820..................... Topeka, KS.................. 24,273
48620..................... Wichita, KS................. 25,945
------------------------------------------------------------------------
Table 3--Low-Volume Hospitals Located In the Mandatory MSAs Eligible To Opt-In During Voluntary Election Period
----------------------------------------------------------------------------------------------------------------
CCN Hospital name MSA MSA Title
----------------------------------------------------------------------------------------------------------------
010034............. Community 33860 Montgomery, AL.
Hospital, Inc.
010062............. Wiregrass 20020 Dothan, AL.
Medical Center.
010095............. Hale County 46220 Tuscaloosa, AL.
Hospital.
010097............. Elmore Community 33860 Montgomery, AL.
Hospital.
010108............. Prattville 33860 Montgomery, AL.
Baptist
Hospital.
010109............. Pickens County 46220 Tuscaloosa, AL.
Medical Center.
010149............. Baptist Medical 33860 Montgomery, AL.
Center East.
040132............. Leo N. Levi 26300 Hot Springs, AR.
National
Arthritis
Hospital.
050040............. LAC-Olive View- 31080 Los Angeles-Long Beach-Anaheim, CA.
UCLA Medical
Center.
050091............. Community 31080 Los Angeles-Long Beach-Anaheim, CA.
Hospital of
Huntington Park.
050137............. Kaiser 31080 Los Angeles-Long Beach-Anaheim, CA.
Foundation
Hospital-
Panorama City.
050138............. Kaiser 31080 Los Angeles-Long Beach-Anaheim, CA.
Foundation
Hospital-Los
Angeles.
050139............. Kaiser 31080 Los Angeles-Long Beach-Anaheim, CA.
Foundation
Hospital-Downey.
050158............. Encino Hospital 31080 Los Angeles-Long Beach-Anaheim, CA.
Medical Center.
050205............. Glendora 31080 Los Angeles-Long Beach-Anaheim, CA.
Community
Hospital.
050373............. LAC+USC Medical 31080 Los Angeles-Long Beach-Anaheim, CA.
Center.
050378............. Pacifica 31080 Los Angeles-Long Beach-Anaheim, CA.
Hospital of the
Valley.
050411............. Kaiser 31080 Los Angeles-Long Beach-Anaheim, CA.
Foundation
Hospital-South
Bay.
050468............. Memorial 31080 Los Angeles-Long Beach-Anaheim, CA.
Hospital of
Gardena.
050543............. College Hospital 31080 Los Angeles-Long Beach-Anaheim, CA.
Costa Mesa.
050548............. Fairview 31080 Los Angeles-Long Beach-Anaheim, CA.
Developmental
Center.
050552............. Motion Picture & 31080 Los Angeles-Long Beach-Anaheim, CA.
Television
Hospital.
050561............. Kaiser 31080 Los Angeles-Long Beach-Anaheim, CA.
Foundation
Hospital-West
Los Angeles.
050609............. Kaiser 31080 Los Angeles-Long Beach-Anaheim, CA.
Foundation
Hospital-Orange
County-Anaheim.
050641............. East Los Angeles 31080 Los Angeles-Long Beach-Anaheim, CA.
Doctors
Hospital.
050677............. Kaiser 31080 Los Angeles-Long Beach-Anaheim, CA.
Foundation
Hospital-
Woodland Hills.
050723............. Kaiser 31080 Los Angeles-Long Beach-Anaheim, CA.
Foundation
Hospital-
Baldwin Park.
050738............. Greater El Monte 31080 Los Angeles-Long Beach-Anaheim, CA.
Community
Hospital.
050744............. Anaheim Global 31080 Los Angeles-Long Beach-Anaheim, CA.
Medical Center.
050747............. South Coast 31080 Los Angeles-Long Beach-Anaheim, CA.
Global Medical
Center.
050751............. Miracle Mile 31080 Los Angeles-Long Beach-Anaheim, CA.
Medical Center.
[[Page 39317]]
050771............. Coast Plaza 31080 Los Angeles-Long Beach-Anaheim, CA.
Hospital.
050776............. College Medical 31080 Los Angeles-Long Beach-Anaheim, CA.
Center.
050779............. Martin Luther 31080 Los Angeles-Long Beach-Anaheim, CA.
King Jr.
Community
Hospital.
050780............. Foothill Medical 31080 Los Angeles-Long Beach-Anaheim, CA.
Center.
050782............. Casa Colina 31080 Los Angeles-Long Beach-Anaheim, CA.
Hospital.
070038............. Connecticut 35300 New Haven-Milford, CT.
Hospice Inc.
070039............. Masonic Home and 35300 New Haven-Milford, CT.
Hospital.
100048............. Jay Hospital.... 37860 Pensacola-Ferry Pass-Brent, FL.
100130............. Lakeside Medical 33100 Miami-Fort Lauderdale-West Palm Beach, FL.
Center.
100240............. Anne Bates Leach 33100 Miami-Fort Lauderdale-West Palm Beach, FL.
Eye Hospital.
100277............. Douglas Gardens 33100 Miami-Fort Lauderdale-West Palm Beach, FL.
Hospital.
100320............. Poinciana 36740 Orlando-Kissimmee-Sanford, FL.
Medical Center.
100326............. Promise Hospital 33100 Miami-Fort Lauderdale-West Palm Beach, FL.
of Miami.
190005............. University 35380 New Orleans-Metairie, LA.
Medical Center
New Orleans.
190011............. University 33740 Monroe, LA.
Health Conway.
190079............. St. Charles 35380 New Orleans-Metairie, LA.
Parish Hospital.
190245............. Monroe Surgical 33740 Monroe, LA.
Hospital.
190300............. St. Charles 35380 New Orleans-Metairie, LA.
Surgical
Hospital LLC.
190302............. Omega Hospital 35380 New Orleans-Metairie, LA.
LLC.
190308............. St. Bernard 35380 New Orleans-Metairie, LA.
Parish Hospital.
190313............. New Orleans East 35380 New Orleans-Metairie, LA.
Hospital.
250012............. Alliance 32820 Memphis, TN-MS-AR.
Healthcare
System.
250126............. North Oak 32820 Memphis, TN-MS-AR.
Regional
Medical Center.
250167............. Methodist Olive 32820 Memphis, TN-MS-AR.
Branch Hospital.
310058............. Bergen Regional 35620 New York-Newark-Jersey City, NY-NJ-PA.
Medical Center.
330080............. Lincoln Medical 35620 New York-Newark-Jersey City, NY-NJ-PA.
& Mental Health
Center.
330086............. Montefiore Mount 35620 New York-Newark-Jersey City, NY-NJ-PA.
Vernon Hospital.
330100............. New York Eye and 35620 New York-Newark-Jersey City, NY-NJ-PA.
Ear Infirmary.
330199............. Metropolitan 35620 New York-Newark-Jersey City, NY-NJ-PA.
Hospital Center.
330231............. Queens Hospital 35620 New York-Newark-Jersey City, NY-NJ-PA.
Center.
330233............. Brookdale 35620 New York-Newark-Jersey City, NY-NJ-PA.
Hospital
Medical Center.
330240............. Harlem Hospital 35620 New York-Newark-Jersey City, NY-NJ-PA.
Center.
330385............. North Central 35620 New York-Newark-Jersey City, NY-NJ-PA.
Bronx Hospital.
330396............. Woodhull Medical 35620 New York-Newark-Jersey City, NY-NJ-PA.
and Mental
Health Center.
330397............. Interfaith 35620 New York-Newark-Jersey City, NY-NJ-PA.
Medical Center.
330399............. St. Barnabas 35620 New York-Newark-Jersey City, NY-NJ-PA.
Hospital.
330405............. Helen Hayes 35620 New York-Newark-Jersey City, NY-NJ-PA.
Hospital.
360241............. Edwin Shaw Rehab 10420 Akron, OH.
Institute.
370011............. Mercy Hospital 36420 Oklahoma City, OK.
El Reno Inc..
370158............. Purcell 36420 Oklahoma City, OK.
Municipal
Hospital.
370199............. Lakeside Women's 36420 Oklahoma City, OK.
Hospital A
Member of
INTEGRIS Health.
370206............. Oklahoma Spine 36420 Oklahoma City, OK.
Hospital.
370215............. Oklahoma Heart 36420 Oklahoma City, OK.
Hospital.
370234............. Oklahoma Heart 36420 Oklahoma City, OK.
Hospital South.
390184............. Highlands 38300 Pittsburgh, PA.
Hospital.
390217............. Excela Health 38300 Pittsburgh, PA.
Frick Hospital.
420057............. McLeod Medical 22500 Florence, SC.
Center-
Darlington.
420066............. Lake City 22500 Florence, SC.
Community
Hospital.
440131............. Baptist Memorial 32820 Memphis, TN-MS-AR.
Hospital Tipton.
450143............. Seton Smithville 12420 Austin-Round Rock, TX.
Regional
Hospital.
450605............. Care Regional 18580 Corpus Christi, TX.
Medical Center.
450690............. University of 46340 Tyler, TX.
Texas Health
Science Center
at Tyler.
450865............. Seton Southwest 12420 Austin-Round Rock, TX.
Hospital.
460043............. Orem Community 39340 Provo-Orem, UT.
Hospital.
670087............. Baylor Scott & 12420 Austin-Round Rock, TX.
White Emergency
Medical Center-
Cedar Park.
----------------------------------------------------------------------------------------------------------------
As stated previously in this section, we are proposing a one-time
participation election period for hospitals with a CCN primary address
located in the voluntary participation MSAs listed in Table 2, low-
volume hospitals specified in Table 3, and rural hospitals in the
mandatory participation MSAs. Based on the anticipated timing for when
the final rule implementing this proposal would be published, we
propose that the voluntary participation election period would begin
January 1, 2018, and would end January 31, 2018. We must receive the
participation election letter no later than January 31, 2018. We are
proposing that the hospital's participation election letter would serve
as the model participant agreement. Voluntary participation would begin
February 1, 2018, and continue through the end of the CJR model, unless
sooner terminated. Thus, participant hospitals located in the voluntary
participation MSAs listed in Table 2, the low-volume hospitals
specified in Table 3, and the rural hospitals in the 34 mandatory
participation MSAs that elect voluntary participation would continue in
the CJR
[[Page 39318]]
model without any disruption to episodes attributed to performance year
3, which begins January 1, 2018. Participant hospitals located in the
voluntary participation MSAs listed in Table 2, the low-volume
hospitals specified in Table 3, and the rural hospitals in the 34
mandatory participation MSAs that do not elect voluntary participation
would be withdrawn from the model effective February 1, 2018, and all
of their performance year 3 episodes up to and including that date
would be canceled, so that these hospitals would not be subject to a
reconciliation payment or repayment amount for performance year 3. We
are proposing to implement our proposed opt-in approach in this manner
as a way to balance several goals, including establishing a uniform
time period for hospitals to make a voluntary participation election,
avoiding disruption of episodes for hospitals that elect to continue
their participation in the CJR model, and preventing confusion about
whether a hospital is participating in performance year 3 of the model.
Specifically, we considered whether adopting a voluntary election
period that ended prior to the start of performance year 3 would be
less confusing and less administratively burdensome in terms of whether
a hospital is participating in performance year 3. To implement this
approach, the voluntary participation election period would have to
close by December 31, 2017, such that each hospital would have made its
determination regarding participation in performance year 3 before the
start of performance year 3 (note that episodes attributed to
performance year 3 would still be canceled under this alternative
approach for eligible hospitals that do not make a participation
election). Because the voluntary election period under this approach
would conclude in advance of the relevant CJR model performance year,
this approach could simplify our administration of performance year 3
by establishing in advance of performance year 3 whether a hospital
would be a participant hospital for the totality of performance year 3.
However, given the timing of this proposed rulemaking, we were not
confident that hospitals would have sufficient time to make a voluntary
participation election by December 31, 2017. Thus, we are proposing
that the voluntary participation election period would occur during the
first month of performance year 3 (that is, throughout January 2018)
and would apply prospectively beginning on February 1, 2018. We believe
this approach will best ensure adequate time for hospitals to make a
participation election while minimizing the time period during which
participation in performance year 3 remains mandatory for all eligible
hospitals in the 67 selected MSAs. We note that based on timing
considerations, including potential changes to the anticipated date of
publication of the final rule, we may modify the dates of the voluntary
participation election period and make conforming changes to the dates
for voluntary participation in performance year 3. We seek comment on
the proposed voluntary participation election period, including whether
we should instead require the participation election to be made by
December 31, 2017 (that is, prior to the start of performance year 3)
or if a different or later voluntary election period may be preferable.
To specify their participation election, we are proposing that
hospitals would submit a written participation election letter to CMS
in a form and manner specified by CMS. We intend to provide templates
that can easily be completed and submitted in order to limit the burden
on hospitals seeking to opt-in. If a hospital with a CCN primary
address located in the voluntary participation MSAs or a low-volume or
rural hospital in the mandatory participation MSAs does not submit a
written participation election letter by January 31, 2018, the
hospital's participation in performance year 3 would end, all of its
performance year 3 episodes would be canceled, and it would not be
included in the CJR model for performance years 4 and 5.
We are proposing a number of requirements for the participation
election letter and that the hospital's participation election letter
would serve as the model participant agreement. First, we are proposing
that the participation election letter must include all of the
following:
Hospital Name.
Hospital Address.
Hospital CCN.
Hospital contact name, telephone number, and email
address.
If selecting the Advanced APM track, attestation of CEHRT
use as defined in Sec. 414.1305.
Second, we are proposing that the participation election letter
must include a certification in a form and manner specific by CMS
that--
The hospital will comply with all requirements of the CJR
model (that is, 42 CFR 510) and all other laws and regulations that are
applicable to its participation in the CJR model; and
Any data or information submitted to CMS will be accurate,
complete and truthful, including, but not limited to, the participation
election letter and any quality data or other information that CMS uses
in reconciliation processes or payment calculations or both.
We solicit feedback on this proposed certification requirement,
including whether the certification should include different or
additional attestations.
Finally, we are proposing that the participation election letter be
signed by the hospital administrator, chief financial officer (CFO) or
chief executive officer (CEO).
We are proposing that, if the hospital's participation election
letter meets these criteria, we would accept the hospital's
participation election. Once a participation election for the CJR model
is made and is effective, the participant hospital would be required to
participate in all activities related to the CJR model for the
remainder of the CJR model unless the hospital's participation is
terminated sooner.
We note that episodes end 90 days after discharge for the CJR model
and episodes that do not start and end in the same calendar year will
be attributed to the following performance year. For example, episodes
that start in October 2017 and do not end on or before December 31,
2017 are attributed to performance year 3. Our methodology for
attributing these episodes to the subsequent performance year would be
problematic in cases where a hospital with a CCN primary address
located in a voluntary participation MSA or a rural hospital or a low-
volume hospital, as specified by CMS, has not elected to voluntarily
continue participating in the model. Therefore, for a hospital with a
CCN primary address located in a voluntary participation MSA, or a
rural hospital or a low-volume hospital, as specified by CMS, that does
not elect voluntary participation during the one-time voluntary
participation election period, we are proposing that all episodes
attributed to performance year 3 for that hospital would be canceled
and would not be included in payment reconciliation. Such hospitals
would have their participation in the CJR model withdrawn effective
February 1, 2018. We note that this proposal is consistent with our
policy for treatment of episodes that have not ended by or on the last
day of performance year 5 and cannot be included in performance year 5
reconciliation due to the end of the model (see Table 8 of the CJR
model final rule (80 FR 73326)).
We are proposing to define a low-volume hospital, mandatory MSA,
and voluntary MSA, to change the definition of participant hospital in
Sec. 510.2, and to amend the specification of the
[[Page 39319]]
geographic areas in Sec. 510.105(a) to reflect the establishment of
mandatory and voluntary participation MSAs. We are proposing to codify
the opt-in proposal in new Sec. 510.115. In addition, we are proposing
to post the list of mandatory participation MSAs, voluntary
participation MSAs, and low-volume hospitals on the CJR model Web site.
We believe our proposed opt-in approach to allow for voluntary
participation in the CJR model by certain hospitals would be less
burdensome on such hospitals than a potential alternative approach of
requiring hospitals to opt-out of the model. In developing the proposal
to allow eligible hospitals located in the proposed 33 voluntary
participation MSAs and low-volume and rural hospitals located in the 34
mandatory participation MSAs to elect voluntary participation, we
considered whether to propose that hospitals would have to make an
affirmative voluntary participation election (that is, an opt-in
approach) or to propose that these hospitals would continue to be
required to participate in the CJR model unless written notification
was given to CMS to withdraw the hospital from the CJR model (that is,
an opt-out approach). We believe an opt-in approach would be less
burdensome on hospitals, because it would not require participation in
the CJR model for hospitals located in the proposed 33 voluntary
participation MSAs and for low-volume and rural hospitals located in
the 34 mandatory participation MSAs unless the hospital affirmatively
chose it. Further, we believe requiring an affirmative opt-in election
would result in less ambiguity about a hospital's participation
intentions as compared to an opt-out approach. Specifically, with an
opt-in approach, a hospital's participation election would document
each hospital's choice, whereas under an opt-out approach there could
be instances where hospitals fail to timely notify CMS of their desire
to withdraw from participation and are thus included in the model and
subject to potential repayment amounts. For these reasons, we have
proposed an opt-in approach. We seek comment on this proposal and the
alternative considered.
We also believe that our proposed approach to make the CJR model
primarily concentrated in the higher cost MSAs where the opportunity
for further efficiencies and care redesign may be more likely and allow
voluntary participation in the lower cost MSAs and for low-volume and
rural hospitals allows the Innovation Center to focus on areas where
the opportunity for further efficiencies and care redesign may be more
likely, while still allowing hospitals in the voluntary MSAs the
opportunity to participate in the model. In developing this proposed
rule, we considered that hospitals in the CJR model have been
participating for over a year and a half as of the timing of this
proposed rule, and we have begun to give hospitals in the model
financial and quality results from the first performance year. In many
cases, participant hospitals have made investments in care redesign,
and we want to recognize such investments and commitments to
improvement while reducing the overall number of hospitals that are
required to participate. We also considered stakeholder feedback that
suggested we make participation in the CJR model voluntary, and the
model size necessary to detect at least a 3-percent reduction in LEJR
episode spending. Taking these considerations into account, we
considered whether revising the model to allow for voluntary
participation in all, some, or none of the 67 selected MSAs would be
feasible.
As discussed in section V. of this proposed rule, the estimated
impact of the changes to the CJR model proposed in this proposed rule
reduces the overall estimated savings for performance years 3, 4, and 5
by $90 million. If voluntary participation was allowed in all of the 67
selected MSAs, the overall estimated model impact would no longer show
savings, and would likely result in additional costs to the Medicare
program. If participation was limited to the proposed 34 mandatory
participation MSAs and voluntary participation was not allowed in any
MSA, the impact to the overall estimated model savings over the last
three years of the model would be closer to $30 million than the $90
million estimate presented in section V. of this proposed rule, because
our modeling, which does not include assumptions about behavioral
changes that might lower fee-for-service spending, estimates that 60 to
80 hospitals will choose voluntary participation. Since we estimate
that these potential voluntary participants would be expected to earn
only positive reconciliation payments under the model, these positive
reconciliation payments would offset some of the savings garnered from
mandatory participants. However, as many current hospital participants
in all of the 67 MSAs are actively invested in the CJR model, we are
proposing to allow voluntary participation in the 33 MSAs that were not
selected for mandatory participation and for low-volume and rural
hospitals. We seek comment on our proposed approach and the
alternatives considered.
A summary of the proposed changes to the CJR model participation
requirements is shown in Table 4.
Table 4--Proposed Participation Requirements for Hospitals in the CJR Model
----------------------------------------------------------------------------------------------------------------
Required to Election
participate as of May elect voluntary Participation effective
February 1, 2018 participation election period date
----------------------------------------------------------------------------------------------------------------
Mandatory Participation MSAs
----------------------------------------------------------------------------------------------------------------
All IPPS participant Yes................... No.................... n/a n/a
hospitals, except rural and
low-volume *.
Rural hospitals *............ No.................... Yes................... 1/1/2018-1/31/2018 2/1/2018
Low-volume hospitals (see No.................... Yes................... 1/1/2018-1/31/2018 2/1/2018
Table 3).
----------------------------------------------------------------------------------------------------------------
Voluntary Participation MSAs
----------------------------------------------------------------------------------------------------------------
All IPPS participant No.................... Yes................... 1/1/2018-1/31/2018 2/1/2018
hospitals.
----------------------------------------------------------------------------------------------------------------
* Note: Participation requirements are based on the CCN status of the hospital as of January 31, 2018. A change
in rural status after the voluntary election period does not affect the participation requirements.
[[Page 39320]]
2. Proposed Codification of CJR Model-Related Evaluation Participation
Requirements
We note that for the CJR model evaluation, the data collection
methods and key evaluation research questions under the proposed
reformulated approach (that is, the proposal for voluntary opt-in
elections discussed in section III.B.1 of this proposed rule) would
remain similar to the approach presented in the CJR model final rule.
The evaluation methodology for the CJR model would be consistent with
the standard Innovation Center approaches we have taken in other
voluntary models such as the Pioneer Accountable Care Organization
(ACO) Model. Cooperation and participation in model-related activities
by all hospitals that participate in the CJR model would continue to be
extremely important to the evaluation. Therefore, with respect to
model-related evaluation activities, we propose to add provisions in
Sec. 510.410(b)(1)(i)(G) to specify that CMS may take remedial action
if a participant hospital, or one of its collaborator, collaboration
agent, or downstream collaboration agent fails to participate in model-
related evaluation activities conducted by CMS and/or its contractors
for any performance year in which the hospital participates. We believe
the addition of this provision would make participation and
collaboration requirements for the CJR model evaluation clear to all
participant hospitals and in particular to hospitals that are eligible
to elect voluntary participation. We seek comment on our proposed
regulatory change.
3. Comment Solicitation: Incentivizing Participation in the CJR Model
In this proposed rule, we are proposing to make participation in
the CJR model voluntary in 33 MSAs and for low-volume and rural
hospitals in the remaining 34 MSAs via the proposed opt-in election
policy discussed in section III.B.1 of this proposed rule. In order to
keep hospitals in all MSAs selected for participation in the CJR model
actively participating in the model, we are soliciting comment on ways
to further incentivize eligible hospitals to elect to continue
participating in the CJR model for the remaining years of the model and
to further incentivize all participant hospitals to advance care
improvements, innovation, and quality for beneficiaries throughout LEJR
episodes.
Additionally, we note that, under the CJR refinements established
in the January 3, 2017 EPM final rule, the total amount of gainsharing
payments for a performance year paid to physicians, non-physician
practitioners, physician group practices (PGPs), and non-physician
practitioner group practices (NPPGPs) must not exceed 50 percent of the
total Medicare approved amounts under the Physician Fee Schedule for
items and services that are furnished to beneficiaries during episodes
that occurred during the same performance year for which the CJR
participant hospital accrued the internal cost savings or earned the
reconciliation payment that comprises the gainsharing payment being
made (Sec. 510.500(c)(4)). Similarly, distribution arrangements are
limited as specified in Sec. 510.505(b)(8), and downstream
distribution arrangements are limited as specified in Sec.
510.506(b)(8). These program integrity safeguards, which are consistent
with the gainsharing caps in other Innovation Center models, were
included to avoid setting an inappropriate financial incentive that may
result in stinting, steering or denial of medically necessary care (80
FR 73415 and 73416). While we are not proposing in this rule any
changes to the gainsharing caps for these models, we have heard various
opinions from stakeholders, including the Medicare Payment Advisory
Commission (MedPAC), on the relative benefit of such limitations on
gainsharing and in this proposed rule we are soliciting comment on this
requirement and any alternative gainsharing caps that may be
appropriate to apply to physicians, non-physician practitioners, PGPs,
and NPPGPs.
C. Maintaining ICD-CM Codes for Quality Measures
In the CJR model final rule (80 FR 73474), we discussed how
specific International Classification of Diseases (ICD)--Clinical
Modifications (CM) procedure codes define group of procedures included
in the Hospital-level risk-standardized complication rate (RSCR)
following elective primary total hip arthroplasty (THA) and/or total
knee arthroplasty (TKA) (NQF #1550) (Hip/Knee Complications) measure.
In discussing quality measures in general, the ICD-CM codes relative to
defining a measure cohort are updated annually and are subject to
change. For example, in the EPM final rule (82 FR 389), we itemized
specific ICD-9-CM and ICD-10-CM codes for Hip/Knee Complications
measure. As quality measures are refined and maintained, the ICD-CM
code values used to identify the relevant diagnosis and/or procedures
included in quality measures can be updated. For example, CMS' Center
for Clinical Standards and Quality (CCSQ) has recently updated the list
of ICD-10 codes used to identify procedures included in the Hip/Knee
Complications measure. We did not intend for our preamble discussions
of certain ICD-CM codes used, for example, to identify procedures
included in the Hip/Knee Complications measures, and therefore the PRO
cohorts for the CJR model, to set a policy that would define the
relevant cohorts for the entirety of the CJR model. We should have also
directed readers to look for the most current codes on the CMS quality
Web site at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html.
To ensure that model participants are aware of periodic ICD-CM code
updates to the Hip/Knee Complications measure, we are proposing to
clarify that participants must use the applicable ICD-CM code set that
is updated and released to the public each calendar year in April by
CCSQ and posted on the Hospital Quality Initiative Measure Methodology
Web site (https://www.cms.gov/medicare/Quality-Initiatives-Patient-
Assessment-Instruments/HospitalQualityInits/Measure-Methodology.html)
for purposes of reporting each of those measures. CMS relies on the
National Quality Forum (NQF) measure maintenance update and review
processes to update substantive aspects of measures every 3 years.
Through NQF's measure maintenance process, NQF endorsed measures are
sometimes updated to incorporate changes that we believe do not
substantially change the nature of the measures. Examples of such
changes include updated diagnosis or procedures codes, changes to
patient population, definitions, or extension of the measure
endorsement to apply to other settings. We believe these types of
maintenance changes are distinct from more substantive changes and do
not require the use of the agency's regulatory process used to update
more detailed aspects of quality measures.
D. Clarification of CJR Reconciliation Following Hospital
Reorganization Event
In the CJR model final rule (80 FR 73348) rule, we discussed our
method of setting target prices using all historical episodes that
would represent our best estimate of historical volume and payments for
participant hospitals when an acquisition, merger, divestiture, or
other reorganization results in a hospital with a new CCN. When a
reorganization event occurs during a performance year,
[[Page 39321]]
CMS updates the quality-adjusted episode target prices for the new or
surviving participant hospital (Sec. 510.300(b)(4)). Following the end
of a performance year, CMS performs annual reconciliation calculations
in accordance with the provisions established in Sec. 510.305. The
annual reconciliation calculations are specific to the episodes
attributable to each participant hospital entity for that performance
year. The applicable quality-adjusted episode target price for such
episodes is the quality-adjusted episode target price that applies to
the episode type as of the anchor hospitalization admission date (Sec.
510.300(a)(3)). For example, if during a performance year, two
participant hospitals (Hospital A and Hospital B) merge under the CCN
of one of those two participant hospital's CCN (Hospital B's CCN),
(assuming no other considerations apply) three initial (and three
subsequent) annual reconciliation calculations for that performance
year are performed: An initial (and subsequent) reconciliation for
Hospital A for the episodes where the anchor hospitalization admission
occurred prior to the merger (as determined by the CCN on the IPPS
claim), using Hospital A's episode target price for that time period;
an initial (and subsequent) reconciliation for Hospital B for the
episodes where anchor hospitalization admission occurred before the
merger (as determined by the CCN on the IPPS claim), using Hospital B's
episode target price for that time period; and an initial (and
subsequent) reconciliation for the post-merger entity (merged Hospitals
A and B) for the episodes where anchor hospitalization admission
occurred on or after the merger's effective date, using the episode
target price that time period. Reorganization events that involve a CJR
model participant hospital and a hospital that is not participating in
the CJR model and result in the new organization operating under the
CJR participant hospital's CCN, would not affect the reconciliation for
the CJR participant hospital for episodes that initiate before the
effective date of the reorganization event. Episodes that initiate
after such reorganization event would be subject to an updated quality-
adjusted episode target price that is based on historical episodes for
the CJR participant hospital which would include historical episode
expenditures for all hospitals that are integrated under the surviving
CCN. These policies have been in effect since the start of the CJR
model on April 1, 2016. To further clarify this policy for the CJR
model, we propose to add a provision specifying that separate
reconciliation calculations are performed for episodes that occur
before and after a reorganization that results in a hospital with a new
CCN at Sec. 510.305(d)(1). We believe this clarification would
increase transparency and understanding of the payment reconciliation
processes for the CJR model. We seek comment on this proposal.
E. Proposed Adjustment to the Pricing Calculation for the CJR
Telehealth HCPCS Codes To Include the Facility PE Values
In the CJR model final rule (80 FR 73450), we established 9 HCPCS
G-codes to report home telehealth evaluation and management (E/M)
visits furnished under the CJR telehealth waiver as displayed in Table
5. These codes have been payable for CJR model beneficiaries since the
CJR model began on April 1, 2016. Pricing for these 9 codes is updated
each calendar year to reflect the work and malpractice (MP) relative
value units (RVUs) for the comparable office and other outpatient E/M
visit codes on the Medicare Physician Fee Schedule (MPFS). As we stated
in the CJR model final rule (80 FR 73450), in finalizing this pricing
method for these codes, we did not include the practice expense (PE)
RVUs of the comparable office and other outpatient E/M visit codes in
the payment rate for these unique CJR model services, based on the
belief that practice expenses incurred to furnish these services are
marginal or are paid for through other MPFS services. However, since
the publication of the CJR model final rule, stakeholders have
expressed concern that the zero value assigned to the PE RVUs for these
codes results in inaccurate pricing. Stakeholders assert that there are
additional costs related to the delivery of telehealth services under
the CJR model such as maintaining the telecommunications equipment,
software and security and that, while these practice expense costs are
not equivalent to in-person service delivery costs, they are greater
than zero. In considering the pricing concerns voiced by stakeholders,
we recognize that there are resource costs in practice expense for
telehealth services furnished remotely, however, we do not believe the
current PE methodology and data accurately account for these costs
relative to the PE resource costs for other services. This belief
previously led us to assign zero PE RVUs in valuing these services, but
because we recognize that there are some costs that are not being
accounted for by the current pricing for these CJR model codes, we
believe an alternative to assigning zero PE RVUs would be to use the
facility PE RVUs for the analogous in-person services. While we
acknowledge that assigning the facility PE RVUs would not provide a
perfect reflection of practice resource costs for remote telehealth
services under the CJR model, in the absence of more specific
information, we believe it is likely a better proxy for such PE costs
than zero. Therefore, we are proposing to use the facility PE RVUs for
the analogous services in pricing the 9 CJR HCPCS G codes shown in
Table 5. Additionally, we are proposing to revise Sec. 510.605(c)(2)
to reflect the addition of the RVUs for comparable codes for the
facility PE to the work and MP RVUs we are currently using for the
basis for payment of the CJR telehealth waiver G codes.
[[Page 39322]]
Table 5--HCPCS Codes for Telehealth Visits for CJR Model Beneficiaries in Home or Place of Residence
--------------------------------------------------------------------------------------------------------------------------------------------------------
Work and MP RVUs equal to
those of the corresponding
office/outpatient E/M visit
HCPCS Code No. Long descriptor Short descriptor CPT code for same calendar
year under the PFS; PE RVUs
equal to the facility
values for each
--------------------------------------------------------------------------------------------------------------------------------------------------------
G9481.................... Remote in-home visit for the evaluation and Remote E/M new pt 10 mins...................... 99201
management of a new patient for use only in
the Medicare-approved Comprehensive Care for
Joint Replacement model, which requires these
3 key components:
A problem focused history.............
A problem focused examination.........
Straightforward medical decision
making, furnished in real time using
interactive audio and video technology..
Counseling and coordination of care with other
physicians, other qualified health care
professionals or agencies are provided
consistent with the nature of the problem(s)
and the needs of the patient or the family or
both. Usually, the presenting problem(s) are
self limited or minor. Typically, 10 minutes
are spent with the patient or family or both
via real time, audio and video
intercommunications technology.
G9482.................... Remote in-home visit for the evaluation and Remote E/M new pt 20 mins...................... 99202
management of a new patient for use only in
the Medicare-approved Comprehensive Care for
Joint Replacement model, which requires these
3 key components:
An expanded problem focused history...
An expanded problem focused
examination..
Straightforward medical decision
making, furnished in real time using
interactive audio and video technology.
Counseling and coordination of care with other
physicians, other qualified health care
professionals or agencies are provided
consistent with the nature of the problem(s)
and the needs of the patient or the family or
both. Usually, the presenting problem(s) are
of low to moderate severity. Typically, 20
minutes are spent with the patient or family
or both via real time, audio and video
intercommunications technology.
G9483.................... Remote in-home visit for the evaluation and Remote E/M new pt 30 mins...................... 99203
management of a new patient for use only in
the Medicare-approved Comprehensive Care for
Joint Replacement model, which requires these
3 key components:
A detailed history....................
A detailed examination................
Medical decision making of low
complexity, furnished in real time using
interactive audio and video technology.
Counseling and coordination of care with other
physicians, other qualified health care
professionals or agencies are provided
consistent with the nature of the problem(s)
and the needs of the patient or the family or
both. Usually, the presenting problem(s) are
of moderate severity. Typically, 30 minutes
are spent with the patient or family or both
via real time, audio and video
intercommunications technology.
G9484.................... Remote in-home visit for the evaluation and Remote E/M new pt 45 mins...................... 99204
management of a new patient for use only in
the Medicare-approved Comprehensive Care for
Joint Replacement model, which requires these
3 key components:
A comprehensive history...............
A comprehensive examination...........
[[Page 39323]]
Medical decision making of moderate
complexity, furnished in real time using
interactive audio and video technology.
Counseling and coordination of care with other
physicians, other qualified health care
professionals or agencies are provided
consistent with the nature of the problem(s)
and the needs of the patient or the family or
both. Usually, the presenting problem(s) are
of moderate to high severity. Typically, 45
minutes are spent with the patient or family
or both via real time, audio and video
intercommunications technology.
G9485.................... Remote in-home visit for the evaluation and Remote E/M new pt 60 mins...................... 99205
management of a new patient for use only in
the Medicare-approved Comprehensive Care for
Joint Replacement model, which requires these
3 key components:
A comprehensive history...............
A comprehensive examination...........
Medical decision making of high
complexity, furnished in real time using
interactive audio and video technology.
Counseling and coordination of care with other
physicians, other qualified health care
professionals or agencies are provided
consistent with the nature of the problem(s)
and the needs of the patient or the family or
both. Usually, the presenting problem(s) are
of moderate to high severity. Typically, 60
minutes are spent with the patient or family
or both via real time, audio and video
intercommunications technology.
G9486.................... Remote in-home visit for the evaluation and Remote E/M est. pt 10 mins..................... 99212
management of an established patient for use
only in the Medicare-approved Comprehensive
Care for Joint Replacement model, which
requires at least 2 of the following 3 key
components:
A problem focused history.............
A problem focused examination.........
Straightforward medical decision
making, furnished in real time using
interactive audio and video technology.
Counseling and coordination of care with other
physicians, other qualified health care
professionals or agencies are provided
consistent with the nature of the problem(s)
and the needs of the patient or the family or
both. Usually, the presenting problem(s) are
self limited or minor. Typically, 10 minutes
are spent with the patient or family or both
via real time, audio and video
intercommunications technology.
G9487.................... Remote in-home visit for the evaluation and Remote E/M est. pt 15 mins..................... 99213
management of an established patient for use
only in the Medicare-approved Comprehensive
Care for Joint Replacement model, which
requires at least 2 of the following 3 key
components:
An expanded problem focused history...
An expanded problem focused
examination..
Medical decision making of low
complexity, furnished in real time using
interactive audio and video technology.
Counseling and coordination of care with other
physicians, other qualified health care
professionals or agencies are provided
consistent with the nature of the problem(s)
and the needs of the patient or the family or
both. Usually, the presenting problem(s) are
of low to moderate severity. Typically, 15
minutes are spent with the patient or family
or both via real time, audio and video
intercommunications technology.
[[Page 39324]]
G9488.................... Remote in-home visit for the evaluation and Remote E/M est. pt 25 mins..................... 99214
management of an established patient for use
only in the Medicare-approved Comprehensive
Care for Joint Replacement model, which
requires at least 2 of the following 3 key
components:
A detailed history....................
A detailed examination................
Medical decision making of moderate
complexity, furnished in real time using
interactive audio and video technology.
Counseling and coordination of care with other
physicians, other qualified health care
professionals or agencies are provided
consistent with the nature of the problem(s)
and the needs of the patient or the family or
both. Usually, the presenting problem(s) are
of moderate to high severity. Typically, 25
minutes are spent with the patient or family
or both via real time, audio and video
intercommunications technology.
G9489.................... Remote in-home visit for the evaluation and Remote E/M est. pt 40 mins..................... 99215
management of an established patient for use
only in the Medicare-approved Comprehensive
Care for Joint Replacement model, which
requires at least 2 of the following 3 key
components:
A comprehensive history...............
A comprehensive examination...........
Medical decision making of high
complexity, furnished in real time using
interactive audio and video technology.
Counseling and coordination of care with other
physicians, other qualified health care
professionals or agencies are provided
consistent with the nature of the problem(s)
and the needs of the patient or the family or
both. Usually, the presenting problem(s) are
of moderate to high severity. Typically, 40
minutes are spent with the patient or family
or both via real time, audio and video
intercommunications technology.
--------------------------------------------------------------------------------------------------------------------------------------------------------
F. Clinician Engagement Lists
1. Background for Submission of Clinician Engagement Lists
Under the Quality Payment Program, the Advanced APM track of the
CJR model does not include eligible clinicians on a Participation List;
rather the CJR Advanced APM track currently includes eligible
clinicians on an Affiliated Practitioner List as defined under Sec.
414.1305 and described under Sec. 414.1425(a)(2) of the agency's
Quality Payment Program regulations. As such, the Affiliated
Practitioner List for the CJR model is the ``CMS-maintained list'' of
eligible clinicians that have ``a contractual relationship with the
Advanced APM Entity [for CJR, the participant hospital] for the
purposes of supporting the Advanced APM Entity's quality or cost goals
under the Advanced APM.'' As specified in our regulations at Sec.
414.1425(a)(2), CMS will use this list to identify the eligible
clinicians who will be assessed as Qualifying APM Participants (QPs)
for the year. CMS will make QP determinations individually for these
eligible clinicians as specified in Sec. Sec. 414.1425(b)(2), (c)(4),
and 414.1435.
In the EPM final rule, we stated that a list of physicians,
nonphysician practitioners, or therapists in a sharing arrangement,
distribution arrangement, or downstream distribution arrangement, as
applicable, would be considered an Affiliated Practitioner List of
eligible clinicians who are affiliated with and support the Advanced
APM Entity in its participation in the Advanced APM for purposes of the
Quality Payment Program. An in-depth discussion of how the clinician
financial arrangement list is considered an Affiliated Practitioner
List can be found in section V.O. of the EPM final rule (82 FR 558
through 563). The clinician financial arrangements list (Sec.
510.120(b)) will be used by CMS to identify eligible clinicians for
whom we would make a QP determination based on services furnished
through the Advanced APM track of the CJR model.
Stakeholders have expressed a desire for model changes that would
also include in the clinician financial arrangement list physicians,
non-physician practitioners, and therapists without a financial
arrangement under the CJR model, but who are affiliated with and
support the Advanced APM Entity in its participation in the Advanced
APM for purposes of the Quality Payment Program.
We agree with stakeholders that these physicians, non-physician
practitioners, and therapists should have their contributions to the
Advanced APM Entity's participation in the Advanced APM recognized
under the Quality Payment Program; however, since these
[[Page 39325]]
individuals do not have financial arrangements with the participant
hospital, to also include them on the clinician financial arrangement
list would be misleading, and could create confusion when CJR model
participant hospitals submit lists to CMS.
2. Proposed Clinician Engagement List Requirements
To increase opportunities for eligible clinicians supporting CJR
model participant hospitals by performing CJR model activities and who
are affiliated with participant hospitals to be considered QPs, we are
proposing that each physician, nonphysician practitioner, or therapist
who is not a CJR collaborator during the period of the CJR model
performance year specified by CMS, but who does have a contractual
relationship with the participant hospital based at least in part on
supporting the participant hospital's quality or cost goals under the
CJR model during the period of the performance year specified by CMS,
would be added to a clinician engagement list.
In addition to the clinician financial arrangement list that is
considered an Affiliated Practitioner List for purposes of the Quality
Payment Program, we propose the clinician engagement list would also be
considered an Affiliated Practitioner List. The clinician engagement
list and the clinician financial arrangement list would be considered
together an Affiliated Practitioner List and would be used by CMS to
identify eligible clinicians for whom we would make a QP determination
based on services furnished through the Advanced APM track of the CJR
model. As specified in Sec. 414.1425, as of our regulations, adopted
in the Calendar Year (CY) 2017 Quality Payment Program final rule (81
FR 77551) (hereinafter referred to as the 2017 QPP final rule), those
physicians, nonphysician practitioners, or therapists who are included
on the CJR model Affiliated Practitioner List as of March 31, June 30,
or August 31 of a QP performance period would be assessed to determine
their QP status for the year. As discussed in the 2017 QPP final rule
(81 FR 77439 and 77440), for clinicians on an Affiliated Practitioner
List, we determine whether clinicians meet the payment amount or
patient count thresholds to be considered QPs (or Partial QPs) for a
year by evaluating whether individual clinicians on an Affiliated
Practitioner List have sufficient payments or patients flowing through
the Advanced APM; we do not make any determination at the APM Entity
level for Advanced APMs in which eligible clinicians are not identified
on a Participation List, but are identified on an Affiliated
Practitioner List. CMS makes the QP determination based on Part B
claims data, so clinicians need not track or report payment amount or
patient count information to CMS.
This proposal would broaden the scope of eligible clinicians that
are considered Affiliated Practitioners under the CJR model to include
those without a financial arrangement under the CJR model but who are
either directly employed by or contractually engaged with a participant
hospital to perform clinical work for the participant hospital when
that clinical work, at least in part, supports the cost and quality
goals of the CJR model. We propose that the cost and quality goals of
the additional affiliated practitioners who are identified on a
clinician engagement list because they are contracted with a
participant hospital must include activities related to CJR model
activities, that is, activities related to promoting accountability for
the quality, cost, and overall care for beneficiaries during LEJR
episodes included in the CJR model, including managing and coordinating
care; encouraging investment in infrastructure, enabling technologies,
and redesigned care processes for high quality and efficient service
delivery; the provision of items and services during a CJR episode in a
manner that reduces costs and improves quality; or carrying out any
other obligation or duty under the CJR model.
Like the requirements of the clinician financial arrangement lists
specified at Sec. 510.120(b), for CMS to make QP determinations for
eligible clinicians based on services furnished through the CJR
Advanced APM track, we would require that accurate information about
each physician, nonphysician practitioner, or therapist who is not a
CJR collaborator during the period of the CJR model performance year
specified by CMS, but who is included on a clinician engagement list,
be provided to CMS in a form and manner specified by CMS on a no more
than quarterly basis. Thus, we propose that each participant hospital
in the Advanced APM track of the CJR model submit to CMS a clinician
engagement list in a form and manner specified by CMS on a no more than
quarterly basis. We propose this list must include the following
information on eligible clinicians for the period of the CJR model
performance year specified by CMS:
For each physician, nonphysician practitioner, or
therapist who is not a CJR collaborator during the period of the CJR
model performance year specified by CMS but who does have a contractual
relationship with a participant hospital based at least in part on
supporting the participant hospital's quality or cost goals under the
CJR model during the period of the CJR model performance year specified
by CMS:
++ The name, TIN, and NPI of the individual.
++ The start date and, if applicable, the end date for the
contractual relationship between the individual and participant
hospital.
Further, we propose that if there are no individuals that meet the
requirements to be reported, as specified in any of Sec. 510.120
(b)(1) through (3) of the EPM final rule or Sec. 510.120(c) as
proposed here, the participant hospital must attest in a form and
manner required by CMS that there are no individuals to report.
Given that this proposal would require submission of a clinician
engagement list, or an attestation that there are no eligible
clinicians to be included on such a list, to reduce burden on
participant hospitals, we would collect information for the clinician
engagement list and clinician financial arrangement list at the same
time.
We seek comments on the proposal for submission of this
information. We are especially interested in comments about approaches
to information submission, including the periodicity and method of
submission to CMS that would minimize the reporting burden on
participant hospitals while providing CMS with sufficient information
about eligible clinicians to facilitate QP determinations.
For each participant hospital in the CJR Advanced APM track, we
propose that the participant hospital must maintain copies of its
clinician engagement lists and supporting documentation (that is,
copies of employment letters or contracts) of its clinical engagement
lists submitted to CMS. Because we would use these lists to develop
Affiliated Practitioner Lists used for purposes of making QP
determinations, these documents would be necessary to assess the
completeness and accuracy of materials submitted by a participant
hospital and to facilitate monitoring and audits. For the same reason,
we further propose that the participant hospital must retain and
provide access to the required documentation in accordance with Sec.
510.110.
[[Page 39326]]
G. Clarification of Use of Amended Composite Quality Score Methodology
During CJR Model Performance Year 1 Subsequent Reconciliation
We conducted the initial reconciliation for performance year 1 of
the CJR model in early 2017, and expect to make reconciliation payments
to CJR participant hospitals by the end of September 2017 to
accommodate the performance year 1 appeals process timelines. We will
conduct the subsequent reconciliation calculation for performance year
1 of the CJR model beginning in the first quarter of 2018, which may
result in additional amounts to be paid to participant hospitals or a
reduction to the amount that was paid for performance year 1. However,
the results of the performance year 1 subsequent reconciliation
calculations will be combined with the performance year 2 initial
reconciliation results before reconciliation payment or repayment
amounts are processed for payment or collection. Changes to the CJR
model established in the EPM final rule impact this process.
The improvements to the CJR model quality measures and composite
quality score methodology, which were finalized in the EPM final rule
(82 FR 524 through 526), were intended to be effective before the CJR
model's performance year 1 initial reconciliation. However, as noted in
section II. of this proposed rule, the effective date for certain EPM
final rule provisions, including those amending Sec. Sec. 510.305 and
510.315 to improve the quality measures and composite quality score
methodology, were delayed until May 20, 2017. As a result, the CJR
reconciliation reports issued in April 2017 were created in accordance
with the provisions of Sec. Sec. 510.305 and 510.315 in effect as of
April 2017; that is, the provisions finalized in the CJR model final
rule. In early 2018, we would perform the performance year 1 subsequent
reconciliation calculation in accordance with the provisions Sec. Sec.
510.305 and 510.315 in effect as of early 2018, that is, established in
the EPM final rule. Applying the provisions established in the EPM
final rule to the performance year 1 subsequent reconciliation
calculation may result in significant differences between the
reconciliation payments calculated during the performance year 1
initial reconciliation and the performance year 1 subsequent
reconciliation. We anticipate that these differences will be greater
than those that would be expected as a result of using more complete
claims and programmatic data that will be available for the subsequent
reconciliation (due to the additional 12 months of time that will occur
between the initial and subsequent reconciliation calculations), more
accurate identification of model overlap and exclusion of episodes, as
well as factoring in adjustments to account for shared savings
payments, and post-episode spending, as specified in Sec. 510.305(i).
Specifically, the methodology used to determine the quality-adjusted
target price for the performance year 1 subsequent reconciliation
calculation will differ from the methodology used to determine the
quality-adjusted target price for the performance year 1 initial
reconciliation calculation as follows: The quality-adjusted target
price would be recalculated to apply the amended reductions to the
effective discount factors (Sec. 510.315(f)), which would be
determined after recalculating the composite quality scores, including
applying more generous criteria for earning quality improvement points
(that is, a 2 decile improvement rather than 3 decile improvement as
specified in amended Sec. 510.315(d)). Using the recalculated quality-
adjusted target price, the net payment reconciliation amount (NPRA)
would be recalculated and will include application of post-episode
spending reductions (Sec. 510.305(j)), as necessary, after determining
the limitations on loss or gain. Thus, calculating performance year 1
reconciliation payments using these two different provisions may result
in a range of upward or downward adjustments to participant hospitals'
performance year 1 payment amounts. We note that a downward adjustment
to the performance year 1 payment amounts would require payment
recoupment, if offset against a performance year 2 initial
reconciliation payment amount is not feasible, which may be burdensome
for participant hospitals.
In developing this proposed rule, we also considered whether there
might be benefit in further delaying the amendments to Sec. Sec.
510.305 and 510.315 such that the same calculations would be used for
both the performance year 1 initial reconciliation and the subsequent
performance year 1 reconciliation, and the use of the amended
calculations would begin with the performance year 2 initial
reconciliation. We believe such an approach would impact future CJR
model implementation and evaluation activities. Because determining the
performance year 2 composite quality score considers the hospital's
quality score improvement from its performance year 1 score, using
different methodologies across performance years would require a
mechanism to account for differences in the quality score methodology,
for example we would have to develop a reliable crosswalk approach. If
we were to develop and use a crosswalk approach, participants and other
stakeholders would need to be informed about the crosswalk methodology
in order to validate data analyses across performance years and that
usage of the crosswalk would be ongoing throughout the model's duration
for consistency across performance years. This methodology could add
substantial complexity to this time-limited model. We also considered
that the composite quality score for some participant hospitals may be
higher under the revised scoring methodology. Delaying use of the
revised scoring methodology may disadvantage these participants if
their composite quality score would be higher and result in a more
favorable discount percentage or allow the hospital to qualify for a
reconciliation payment. Therefore, we believe the best approach is to
apply the quality specifications as established in the EPM final rule
(that is, the amendments to Sec. Sec. 510.305 and 510.315 that became
effective May 20, 2017) to performance year 1 subsequent reconciliation
calculations to ensure that reconciliation calculations for subsequent
performance years will be calculated using the same methodology and to
improve consistency across performance years for quality improvement
measurement. Thus, for the reasons noted previously, we are not
proposing to change the amendments to Sec. Sec. 510.305 and 510.315
that became effective May 20, 2017. We seek comment on whether using an
alternative approach, such as the quality composite score methodology
from the CJR model final rule for the performance year 1 subsequent
reconciliation, would ensure better consistency for analyses across CJR
performance years.
H. Clarifying and Technical Changes Regarding the Use of the CMS Price
(Payment) Standardization Detailed Methodology
Based on questions we received from participant hospitals during
the performance year 1 reconciliation process, we are proposing to make
two technical changes to the CJR model regulations to clarify the use
of the CMS Price (Payment) Standardization Detailed Methodology, posted
on the QualityNet Web site at https://www.qualitynet.org/dcs/
ContentServer?c=Page&pagename=Qnet
[[Page 39327]]
Public%2FPage%2FQnetTier4&cid=1228772057350, in the calculation of
target prices and actual episode spending. This pricing standardization
approach is the same as that used for the Hospital Value-Based
Purchasing Program's (HVBP) Medicare spending per beneficiary metric.
In section III.C.3.a. of the CJR model final rule (80 FR 73331 through
73333), we finalized how we would operationalize the exclusion of the
various special payment provisions in calculating CJR model episode
expenditures, both historical episode spending and performance year
episode spending, by relying upon the CMS Price (Payment)
Standardization Detailed Methodology with modifications. However, we
did not clearly articulate this finalized policy in the regulations at
42 CFR part 510. Thus, we are proposing the following technical changes
to bring the regulatory text into conformity with our intended policy
and to reduce potential stakeholder uncertainty about how the price
(payment) standardization methodology is used. We are proposing to
insert ``standardized'' into the definition of actual episode payment
in Sec. 510.2, and insert ``with certain modifications'' into Sec.
510.300(b)(6) to account for the modifications we must make to the
standardization methodology to ensure all pricing calculations are
consistent with our finalized policies.
IV. Collection of Information Requirements
As stated in section 1115A(d)(3) of the Act, Chapter 35 of title
44, United States Code, shall not apply to the testing and evaluation
of models under section 1115A of the Act. As a result, the information
collection requirements contained in this proposed rule need not be
reviewed by the Office of Management and Budget. However, we have,
summarized the anticipated cost burden associated with the information
collection requirements in the Regulatory Impact Analysis section of
this proposed rule.
V. Regulatory Impact Analysis
A. Introduction
We have examined the impacts of this rule as required by Executive
Order 12866 on Regulatory Planning and Review (September 30, 1993),
Executive Order 13563 on Improving Regulation and Regulatory Review
(January 18, 2011), the Regulatory Flexibility Act (RFA) (September 19,
1980, Pub. L. 96-354), section 1102(b) of the Social Security Act,
section 202 of the Unfunded Mandates Reform Act of 1995 (March 22,
1995; Pub. L. 104-4), Executive Order 13132 on Federalism (August 4,
1999) and the Congressional Review Act (5 U.S.C. 804(2)), and Executive
Order 13771 on Reducing Regulation and Controlling Regulatory Costs
(January 30, 2017).
Executive Orders 12866 and 13563 direct agencies to assess all
costs and benefits of available regulatory alternatives and, if
regulation is necessary, to select regulatory approaches that maximize
net benefits (including potential economic, environmental, public
health and safety effects, distributive impacts, and equity). A
regulatory impact analysis (RIA) must be prepared for major rules with
economically significant effects ($100 million or more in any 1 year).
This proposed rule proposes to cancel the EPMs and the CR incentive
payment model in advance of their start date and proposes several
revisions to the design of the CJR model; these proposals impact a
subset of hospitals under the IPPS. Therefore, it would have a
relatively small economic impact; as a result, this proposed rule does
not reach the $100 million threshold and thus is neither an
``economically significant'' rule under E.O. 12866, nor a ``major
rule'' under the Congressional Review Act.
B. Statement of Need
As discussed previously, review and reevaluation of policies and
programs, as well as revised rulemaking, are within an agency's
discretion, especially after a change in administration occurs. After
review and reevaluation of the CJR model final rule, the EPM final rule
and the public comments we received in response to the March 21, 2017
IFC, in addition to other considerations, we have determined that it is
necessary to propose to rescind the regulations at 42 CFR part 512 and
to reduce the geographic scope of the CJR model for the following
reasons. First, we believe that requiring hospitals to participate in
additional episode models at this time is not in the best interest of
the agency or affected providers. We are concerned that engaging in
large mandatory episode payment model efforts at this time may impede
our ability to pursue and engage providers, such as hospitals, in
future voluntary efforts. Similarly, we also believe that reducing the
number of providers required to participate in the CJR model would
allow us to continue to evaluate the effects of such a model while
limiting the geographic reach of our current mandatory models. Finally,
we believe that canceling the EPMs and CR incentive payment model, as
well as altering the scope of the CJR model, offers CMS maximum
flexibility to design alternative episode-based models and make
potential improvements to these models as suggested by stakeholders,
while still allowing us to test and evaluate the impact of the CJR
model on the quality of care and expenditures.
This proposed rule is also necessary to propose improvements to the
CJR model for performance years 3, 4, and 5. We are proposing a few
technical refinements and clarifications for certain payment,
reconciliation and quality provisions, and a change to the criteria for
the Affiliated Practitioner List to broaden the CJR Advanced APM track
to additional eligible clinicians. We believe these proposed
refinements would address operational issues identified since the start
of the CJR model.
C. Anticipated Effects
In section III. of the preamble to this proposed rule, we discuss
our proposals to amend the regulations governing the CJR model. We
present the following estimated overall impact of these proposed
changes to the CJR model. Table 6 summarizes the newly calculated
estimated impact for the CJR model for the last 3 years of the model.
The modeling methodology for provider performance and participation
is consistent with the methodology used in modeling the CJR impacts in
the EPM final rule (82 FR 596). However, we updated our analysis to
include an opt-in option for hospitals in 33 of the 67 MSAs selected
for participation in the CJR model (all but 4 of these MSAs are from
the lower cost groups), while maintaining mandatory participation for
the remaining 34 MSAs (all of which are from the higher cost groups),
and allowing for the exclusion of low-volume and rural hospitals in
these 34 MSAs from mandatory participation and allowing them to choose
voluntary participation (opt-in). We would expect the number of
mandatory participating hospitals from year 3 forward to decrease from
approximately 700, which is approximately the number of current CJR
participants, to approximately 393. We assumed that if a hospital would
exceed its target pricing such that it would incur an obligation of
repayment to CMS of 3 percent or more in a given year, that hospital
would not elect voluntary participation in the model for the final
three performance years. We assumed no low-volume providers would
participate, noting that including them in impacts would not have any
noticeable effects due to their low claims volume. For purposes of
[[Page 39328]]
identifying CJR rural hospitals for this impact, we used the 2017 IPPS
Sec. 412.103 rural reclassification list. We found only one provider
in the 34 mandatory MSAs with an active rural reclassification and this
provider was also on the low-volume hospital list and was not included
in the impacts. The likelihood of voluntary participation linearly
increases based on an upper bound of 3 percent bonus, but the modeling
assumes that 25 percent of hospitals in the voluntary MSAs would not
consider participation so that the likelihood of participation for each
hospital is capped at 75 percent; we expect 60 to 80 hospitals to elect
voluntary participation in the model.
We seek comment on our assumptions about the number of hospitals
that would elect voluntary participation in the CJR model. Due to a
lack of available data, we did not account for participant investment
in the impact analysis model we used for this proposed rule. However,
we would expect that those who choose to voluntarily participate would
have made investments in the CJR model that enable them to perform well
and that they would anticipate earning positive reconciliation
payments. For those hospitals choosing not to voluntarily participate,
we would expect that the cost of any investments they may have made
based on their participation in performance years 1 and 2 of the CJR
model would be outweighed by the reconciliation payment obligations
they would expect to incur if they continued to participate. The 60 to
80 participants we expect to continue participating in the model
through the voluntary election process are not included in our previous
estimate of 393 CJR participants in the mandatory MSAs. Thus, in total
we expect approximately 450 to 470 participants in the CJR model for
the final three performance years. The participation parameters were
chosen to reflect both the anticipated risk aversion of providers, and
an expectation that many participants do not remain in an optional
model or demonstration when there is an expectation that the hospital
would incur an obligation of repayment to CMS. These assumptions
reflect the experience with other models and demonstrations. The value
of 3 percent may be somewhat larger than the level of repayment at
which providers would opt-in, but the value was chosen to allow for the
uncertainty of expected claims. We note that the possibility of
shifting episodes from CJR model participant hospitals to low-volume or
other non-participating hospitals exists and that we did not include
any assumptions of this potential behavior in our financial impact
modeling. We seek comment on our model assumptions that shifting of
episodes will not occur. The new calculations estimate that the CJR
model would result in a net Medicare program savings of approximately
$204 million over the 3 remaining performance years (2018 through
2020). This represents a reduction in savings of approximately $90
million from the estimated net financial impacts of the CJR model in
the EPM final rule (82 FR 603).
Our previous analyses of the CJR model did not explicitly model for
utilization changes, such as improvements in the efficiency of service
during episodes. However, these behavioral changes would have minimal
effect on the Medicare financial impacts. If the actual costs for an
episode are below the discounted bundled payment amount, then CMS
distributes the difference between these two amounts to the participant
hospital, up to a capped amount. Similarly, if actual costs for an
episode are above the discounted bundled payment amount, then the
participant hospital pays CMS the difference between these amounts, up
to a capped amount. Due to the uncertainty of estimating the impacts of
this model, actual results could be higher or lower than this estimate.
Table 6--Comparison of Initial Estimate of the Impact on the Medicare Program of the CJR Model With Revised
Estimates
[Figures are in $ millions, negative values represent savings]
----------------------------------------------------------------------------------------------------------------
Year 2018 2019 2020 Total
----------------------------------------------------------------------------------------------------------------
Initial CJR Estimate............................ -61 -109 -125 -294
Revised CJR Estimate............................ -38 -77 -88 -204
Change.......................................... 22 32 36 90
----------------------------------------------------------------------------------------------------------------
Note: The initial estimate includes the changes to the CJR model finalized in the EPM final rule (82 FR 603).
The 2016 and 2017 initial estimate is not impacted by the proposed changes to the CJR model in this proposed
rule. The total column reflects 2018 through 2020. Totals do not necessarily equal the sums of rounded
components.
Our analysis presents the cost and transfer payment effects of this
proposed rule to the best of our ability.
D. Effects on Beneficiaries
We believe that the proposal to cancel the EPMs and CR incentive
payment model would not affect beneficiaries' freedom of choice to
obtain healthcare services from any individual or organization
qualified to participate in the Medicare program, including providers
that are making care improvements within their communities. Although
these models seek to incentivize care redesign and collaboration
throughout the inpatient and post-acute care spectrum, the models have
not yet begun. As the current baseline assumes these models would
become effective on January 1, 2018, and that these models would
incentivize care improvements that would likely result in an increase
in quality of care for beneficiaries, it is possible that the proposal
to cancel these models could cause hospitals that potentially made
improvements in care in anticipation of the start of these models to
delay or cease these investments, which could result in a reversal of
any recent quality improvements. However, we believe the concerns
raised by stakeholders and the lack of time to consider design
improvements for these models prior to the January 1, 2018 start date
outweigh potential reversal of any recent improvements in care
potentially made by some hospitals and warrant cancellation of these
models at this time while we engage with stakeholders to identify
future tests for bundled payments and incentivizing high value care.
We believe that the proposed changes to the CJR model discussed in
this proposed rule, specifically focusing the model on higher cost MSAs
in which participation would continue to be mandatory and allowing low-
volume and rural hospitals and all participant hospitals in lower cost
MSAs to choose voluntary participation, would maintain the potential
benefits of the CJR model for beneficiaries in many areas while
providing a substantial number of
[[Page 39329]]
hospitals with increased flexibility to better focus on priority needs
of the beneficiaries they serve. Specifically, low-volume and rural
hospitals as well as other hospitals in the 33 voluntary participation
MSAs (which are relatively more efficient areas) could elect to
participate in the CJR model if they believe that doing so best meets
their organization's strategic priorities for serving the beneficiaries
in their community. Alternatively, if these hospitals do not believe
continued participation in the CJR model would benefit their
organizational goals and local patient care priorities, they can elect
not to opt-in for the remainder of the model. We believe that
beneficiaries in the service areas of the hospitals that would be
allowed to choose to participate in the CJR model under our proposal
may have an ongoing benefit from the care redesign investments these
hospitals have already made during the first 2 years of the CJR model.
Overall, we believe the refinements to the CJR model proposed in this
proposed rule do not materially alter the potential effects of the
model on beneficiaries. However, we acknowledge the possibility that
the improved quality of care that was likely to have occurred during
performance years 1 and 2 of the CJR model may be curtailed for
beneficiaries that receive care at hospitals that do not elect to
continue participation in the CJR model.
E. Effects on Small Rural Hospitals
The changes to the CJR model proposed in this proposed rule do not
substantially alter our previous impacts of the impact on small,
geographically rural hospitals specified in either the EPM final rule
(82 FR 606) and the CJR model final rule (80 FR 73538) because we
continue to believe that few geographically rural hospitals will be
included in the CJR model. In addition, the proposal to allow all rural
hospitals (as defined in Sec. 510.2) that are not otherwise excluded
the opportunity to elect to opt-in to the CJR model instead of having a
mandatory participation requirement may further reduce the likelihood
that rural hospitals would be included in the model. We solicit public
comment on our estimates and analysis of the impact of our proposals on
small rural hospitals.
F. Effects on Small Entities
The RFA requires agencies to analyze options for regulatory relief
of small entities, if a rule has a significant impact on a substantial
number of small entities. For purposes of the RFA, small entities
include small businesses, nonprofit organizations, and small
governmental jurisdictions. We estimate that most hospitals and most
other providers and suppliers are small entities, either by virtue of
their nonprofit status or by qualifying as small businesses under the
Small Business Administration's size standards (revenues of less than
$7.5 to $38.5 million in any 1 year; NAIC Sector--62 series). States
and individuals are not included in the definition of a small entity.
For details, see the Small Business Administration's Web site at https://www.sba.gov/content/smallbusiness-size-standards.
For purposes of the RFA, we generally consider all hospitals and
other providers and suppliers to be small entities. We believe that the
provisions of this proposed rule relating to acute care hospitals would
have some effects on a substantial number of other providers involved
in these episodes of care including surgeons and other physicians,
skilled nursing facilities, physical therapists, and other providers.
Although we acknowledge that many of the affected entities are small
entities, and the analysis discussed throughout this proposed rule
discusses aspects of episode payment models that may or would affect
them, we have no reason to assume that these effects would reach the
threshold level of 3 percent of revenues used by HHS to identify what
are likely to be ``significant'' impacts. We assume that all or almost
all of these entities would continue to serve these patients, and to
receive payments commensurate with their cost of care. Hospitals
currently experience frequent changes to payment (for example, as both
hospital affiliations and preferred provider networks change) that may
impact revenue, and we have no reason to assume that this would change
significantly under the changes proposed in this rule.
Accordingly, we have determined that this proposed rule will not
have a significant impact on a substantial number of small entities. We
solicit public comments on our estimates and analysis of the impact of
our proposals on those small entities.
G. Effects of Information Collection
The changes proposed in this proposed rule would have a minimal
additional burden of information collection for CJR model participant
hospitals. The two areas which this proposed rule may increase
participant burden include providing clinician engagement lists and
submitting opt-in documentation (for eligible hospitals who choose to
opt-in to the CJR model).
Clinician engagement list submission for the CJR model would
require that participants submit on a no more than quarterly basis a
list of physicians, nonphysician practitioners, or therapists who are
not a CJR model collaborator during the period of the CJR model
performance year specified by CMS but who do have a contractual
relationship with a CJR model participant hospital based at least in
part on supporting the participant hospital's quality or cost goals
under the CJR model during the period of the performance year specified
by CMS.
For hospitals eligible to opt-in to the CJR model that elect to
participate in the model, CMS intends to provide a template that can be
completed and submitted prior to the proposed January 31, 2018
submission deadline. As stated previously, we estimate that the number
of hospitals that will elect voluntary participation in CJR is 60 to
80. As stated previously, this template would be designed to minimize
burden on participants, particularly since all necessary information
required to effectively opt-in will be included within the template.
Using wage information from the Bureau of Labor Statistics for medical
and health service managers (Code 11-9111), we assumed a rate of
$105.16 per hour, including overhead and fringe benefits (https://www.bls.gov/oes/current/oes_nat.htm) and estimated that the time to
complete the opt-in template would be, on average, approximately 30
minutes per hospital. Thus, total costs associated with completing opt-
in templates for all 60 to 80 hospitals projected to elect voluntary
participation is expected to range between $3,150 (60 hospitals) and
$4,200 (80 hospitals).
We seek comment on our assumptions and information on any costs
associated with this work.
H. Regulatory Review Costs
If regulations impose administrative costs on private entities,
such as the time needed to read and interpret this proposed rule, we
should estimate the cost associated with regulatory review. Due to the
uncertainty involved with accurately quantifying the number of entities
that will review the rule, we assume that the total number of unique
commenters on the EPM proposed rule will be the number of reviewers of
this proposed rule. We acknowledge that this assumption may understate
or overstate the costs of reviewing this rule. It is possible that not
all commenters reviewed the precedent rule in detail, and it is also
possible that some reviewers chose not to comment on the proposed rule.
For these reasons we thought that the number of past commenters on the
EPM proposed rule
[[Page 39330]]
would be a fair estimate of the number of reviewers of this rule. We
welcome any comments on the approach in estimating the number of
entities that would review this proposed rule.
We also recognize that different types of entities are in many
cases affected by mutually exclusive sections of this proposed rule,
however for the purposes of our estimate we assume that each reviewer
reads approximately 100 percent of the rule. We seek comments on this
assumption.
Using the wage information from the BLS for medical and health
service managers (Code 11-9111), we estimate that the cost of reviewing
this rule is $105.16 per hour, including overhead and fringe benefits
https://www.bls.gov/oes/current/oes_nat.htm. Assuming an average
reading speed, we estimate that it would take approximately 1.6 hours
for the staff to review this proposed rule. For each entity that
reviews the rule, the estimated cost is $168.26 (1.6 hours x $105.16).
Therefore, we estimate that the total cost of reviewing this regulation
is $29,445 ($105.16 x 175 reviewers).
I. Unfunded Mandates
Section 202 of the Unfunded Mandates Reform Act of 1995 (UMRA) also
requires that agencies assess anticipated costs and benefits before
issuing any rule whose mandates require spending in any 1 year of $100
million in 1995 dollars, updated annually for inflation. In 2017, that
is approximately $148 million. This proposed rule does not include any
mandate that would result in spending by state, local or tribal
governments, in the aggregate, or by the private sector in the amount
of $148 million in any 1 year.
J. Federalism
We do not believe that there is anything in this proposed rule that
either explicitly or implicitly preempts any state law, and furthermore
we do not believe that this proposed rule would have a substantial
direct effect on state or local governments, preempt state law, or
otherwise have a federalism implication.
K. Reducing Regulation and Controlling Regulatory Costs
Executive Order 13771, titled Reducing Regulation and Controlling
Regulatory Costs (82 FR 9339), was issued on January 30, 2017. This
proposed rule, if finalized as proposed, is not expected to be subject
to the requirements of E.O. 13771 because it is estimated to result in
no more than de minimis costs.
L. Alternatives Considered
Throughout this proposed rule, we have identified our proposed
policies and alternatives that we have considered, and provided
information as to the effects of these alternatives and the rationale
for each of the proposed policies. We considered but did not propose to
allow voluntary participation in all of the 67 selected MSAs in the CJR
model because the overall estimated CJR model impact would no longer
show savings, and would likely result in costs. An entirely voluntary
CJR model would likely result in costs due to the assumption that, in
aggregate, hospitals that expect to receive a positive reconciliation
payment from Medicare would elect to opt-in to the model while
hospitals that expect to owe Medicare a reconciliation amount would not
likely elect to participate in the model. We also considered but did
not propose limiting participation to the proposed 34 mandatory
participation MSAs and not allowing voluntary participation in any of
the 67 selected MSAs. If participation was limited to the proposed 34
mandatory participation MSAs and voluntary participation was not
allowed in any MSA, the impact to the overall estimated model savings
over the last three years of the model would be closer to $30 million
than the $90 million estimate presented in section V. of this proposed
rule, because our modeling does not include assumptions about
behavioral changes that might lower fee-for-service spending. Since our
impact model estimates that 60 to 80 hospitals would choose voluntary
participation and that these potential voluntary participants would be
expected to earn only positive reconciliation payments under the model,
these positive payments to the voluntary participants would offset some
of the savings garnered from mandatory participants. However, we are
proposing to allow voluntary participation in the proposed 33 voluntary
participation MSAs and for low-volume and rural hospitals to permit
hospitals that have made investments in care redesign and commitments
to improvement to continue to participate in the model for the
remaining 3 years. We believe our proposal would benefit a greater
number of beneficiaries because a greater number of hospitals would be
included in the CJR model.
Instead of proposing to cancel the EPMs and CR incentive payment
model, we considered altering the design of these models to allow for
voluntary participation but as this would potentially involve
restructuring the model design, payment methodologies, financial
arrangement provisions and/or quality measures, we did not believe that
such alterations would offer providers enough time to prepare for such
changes, given the planned January 1, 2018 start date. In addition, if
at a later date we decide to offer these models, or similar models, on
a voluntary basis, we would not expect to implement them through
rulemaking, but rather would establish them consistent with the manner
in which we have implemented other voluntary models.
We solicit and welcome comments on our proposals, on the
alternatives we have identified, and on other alternatives that we
should consider, as well as on the costs, benefits, or other effects of
these.
M. Accounting Statement and Table
As required by OMB Circular A-4 under Executive Order 12866
(available at https://www.whitehouse.gov/omb/circulars_a004_a-4) in
Table 7, we have prepared an accounting statement showing the
classification of transfers associated with the provisions in this
proposed rule. The accounting statement is based on estimates provided
in this regulatory impact analysis. As described in Table 6, we
estimate the proposed changes to the CJR model would continue to result
in savings to the federal government of approximately $204 million over
the 3 remaining performance years of the model from 2018 to 2020,
noting these changes do reduce the original CJR estimated savings by
approximately $90 million. In Table 7, the overall annualized change in
payments (for all provisions in this proposed rule relative to the CJR
model as originally finalized) based on a 7-percent and 3-percent
discount rate, results in net federal monetary transfer from the
federal government to participant IPPS hospitals of $73.2 million and
$82.4 million in 2017 dollars, respectively, over the period of 2018 to
2020.
[[Page 39331]]
Table 7--Accounting Statement Changes to Comprehensive Care for Joint Replacement Model for Performance Years
2018 to 2020
----------------------------------------------------------------------------------------------------------------
Units
---------------------------------------------------------------
Category Estimates Discount rate
Year dollar (%) Period covered
----------------------------------------------------------------------------------------------------------------
Costs: *
Upfront cost of regulation 0.03 2017 7 2018 upfront cost.
($million). 0.03 2017 3 2018 upfront cost.
----------------------------------------------------------------------------------------------------------------
From Whom to Whom Incurred by IPPS Hospitals as a result of this regulation.
----------------------------------------------------------------------------------------------------------------
Transfers:
Annualized/Monetized 27.90 2017 7 2018-2020.
($million/year). 29.14 2017 3 2018-2020.
----------------------------------------------------------------------------------------------------------------
From Whom To Whom From the Federal Government to Participating IPPS Hospitals.
----------------------------------------------------------------------------------------------------------------
* The cost includes the regulatory familiarization and completing opt-in templates for up to 80 hospitals to
join the CJR model.
M. Conclusion
This analysis, together with the remainder of this preamble,
provides the Regulatory Impact Analysis of a rule. As a result of this
proposed rule, we estimate that the financial impact of the changes to
the CJR model proposed here would result in a reduction to previously
estimated savings by $90 million over the 3 remaining performance years
(2018 through 2020) although we note that the CJR model would still be
estimated to save the Medicare program approximately $204 million over
the remaining three performance years.
In accordance with the provisions of Executive Order 12866, this
rule was reviewed by the Office of Management and Budget.
VI. Response to Comments
Because of the large number of public comments we normally receive
on Federal Register documents, we are not able to acknowledge or
respond to them individually. We will consider all comments we receive
by the date and time specified in the DATES section of this preamble,
and, when we proceed with a subsequent document, we will respond to the
comments in the preamble to that document.
List of Subjects
42 CFR Part 510
Administrative Practice and Procedure, Health facilities, Health
professions, Medicare, and Reporting and recordkeeping requirements.
42 CFR Part 512
Administrative Practice and Procedure, Health facilities, Health
professions, Medicare, and Reporting and recordkeeping requirements.
For the reasons set forth in the preamble, under the authority at
section 1115A of the Social Security Act, the Centers for Medicare &
Medicaid Services proposes to amend 42 CFR Chapter IV, as follows:
PART 510--COMPREHENSIVE CARE FOR JOINT REPLACEMENT MODEL
0
1. The authority citation for part 510 continues to read as follows:
Authority: Secs. 1102, 1115A, and 1871 of the Social Security
Act (42 U.S.C. 1302, 1315(a), and 1395hh).
0
2. Section 510.2 is amended by--
0
a. Revising the definition of ``Actual episode payment'';
0
b. Adding, in alphabetical order, definitions of ``Low-volume
hospital'' and ``mandatory MSA''.
0
c. Revising the definition of ``participant hospital''; and
0
d. Adding the definition of ``voluntary MSA''.
The revisions and additions read as follows:
Sec. 510.2 Definitions.
* * * * *
Actual episode payment means the sum of standardized Medicare
claims payments for the items and services that are included in the
episode in accordance with Sec. 510.200(b), excluding the items and
services described in Sec. 510.200(d).
* * * * *
Low-volume hospital means a hospital identified by CMS as having
fewer than 20 LEJR episodes in total across the 3 historical years of
data used to calculate the performance year 1 CJR episode target
prices.
* * * * *
Mandatory MSA means an MSA designated by CMS as a mandatory
participation MSA in accordance with Sec. 510.105(a).
* * * * *
Participant hospital means one of the following:
(1) During performance years 1 and 2 of the CJR model and the
period from January 1, 2018 to January 31, 2018 of performance year 3,
a hospital (other than a hospital excepted under Sec. 510.100(b)) with
a CCN primary address located in one of the geographic areas selected
for participation in the CJR model in accordance with Sec. 510.105.
(2) Beginning February 1, 2018, a hospital (other than a hospital
excepted under Sec. 510.100(b)) that is one of the following:
(i) A hospital with a CCN primary address located in a mandatory
MSA as of February 1, 2018 that is not a rural hospital or a low-volume
hospital on that date.
(ii) A hospital that is a rural hospital or low-volume hospital
with a CCN primary address located in a mandatory MSA that makes an
election to participate in the CJR model in accordance with Sec.
510.115.
(iii) A hospital with a CCN primary address located in a voluntary
MSA that makes an election to participate in the CJR model in
accordance with Sec. 510.115.
* * * * *
Voluntary MSA means an MSA designated by CMS as a voluntary
participation MSA in accordance with Sec. 510.105(a).
0
3. Section 510.105 is amended by revising paragraph (a) to read as
follows:
Sec. 510.105 Geographic areas.
(a) General. The geographic areas for inclusion in the CJR model
are obtained based on a stratified random sampling of certain MSAs in
the United States.
(1) All counties within each of the selected MSAs are selected for
inclusion in the CJR model.
[[Page 39332]]
(2) Beginning with performance year 3, the selected MSAs are
designated as either mandatory participation MSAs or voluntary
participation MSAs.
* * * * *
0
4. Section 510.115 is added to read as follows:
Sec. 510.115 Voluntary participation election.
(a) General. To continue participation in performance year 3 and
participate in performance year 4 and performance year 5, the following
hospitals must submit a written participation election letter as
described in paragraph (c) of this section during the voluntary
participation election period specified in paragraph (b) of this
section:
(1) Hospitals (other than those excluded under Sec. 510.100(b))
with a CCN primary address in a voluntary MSA.
(2) Low-volume hospitals with a CCN primary address in a mandatory
MSA.
(3) Rural hospitals with a CCN primary address in a mandatory MSA.
(b) Voluntary participation election period. The voluntary
participation election period begins on January 1, 2018 and ends on
January 31, 2018.
(c) Voluntary participation election letter. The voluntary
participation election letter serves as the model participation
agreement. CMS accepts the voluntary participation election letter if
the letter meets all of the following criteria:
(1) Includes the following:
(i) Hospital name.
(ii) Hospital address.
(iii) Hospital CCN.
(iv) Hospital contact name, telephone number, and email address.
(v) Model name (that is, CJR model).
(vi) Attestation of CEHRT use as specified in Sec. 510.120(a)(1)
(if the hospital is choosing to participate in the Advanced APM track).
(2) Includes a certification that the hospital will--
(i) Comply with all applicable requirements of this part and all
other laws and regulations applicable to its participation in the CJR
model; and
(ii) Submit data or information to CMS that is accurate, complete
and truthful, including, but not limited to, the participation election
letter and any quality data or other information that CMS uses in its
reconciliation processes.
(3) Is signed by the hospital administrator, CFO or CEO.
(4) Is submitted in the form and manner specified by CMS.
0
5. Section 510.120, as added January 3, 2017 (82 FR 180), delayed until
October 1, 2017, on March 21, 2017 (82 FR 14464), further delayed until
January 1, 2018, on May 19, 2017 (82 FR 22895), is amended by removing
paragraph (b)(4), revising paragraph (c), and adding paragraphs (d) and
(e).
The revision and additions read as follows:
Sec. 510.120 CJR participant hospital CEHRT track requirements.
* * * * *
(c) Clinician engagement list. Each participant hospital that
chooses CEHRT use as provided in paragraph (a)(1) of this section must
submit to CMS a clinician engagement list in a form and manner
specified by CMS on a no more than quarterly basis. This list must
include the following information on individuals for the period of the
performance year specified by CMS:
(1) For each physician, nonphysician practitioner, or therapist who
is not a CJR collaborator during the period of the CJR model
performance year specified by CMS but who does have a contractual
relationship with the participant hospital based at least in part on
supporting the participant hospital's quality or cost goals under the
CJR model during the period of the performance year specified by CMS:
(i) The name, TIN, and NPI of the individual.
(ii) The start date and, if applicable, the end date for the
contractual relationship between the individual and participant
hospital.
(2) [Reserved]
(d) Attestation to no individuals. If there are no individuals that
meet the requirements to be reported, as specified in paragraphs (b)(1)
through (3) or paragraph (c) of this section, the participant hospital
must attest in a form and manner required by CMS that there are no
individuals to report.
(e) Documentation requirements. (1) Each participant hospital that
chooses CEHRT use as provided in paragraph (a)(1) of this section must
maintain documentation of their attestation to CEHRT use, clinician
financial arrangements lists, and clinician engagement lists.
(2) The participant hospital must retain and provide access to the
required documentation in accordance with Sec. 510.110.
0
6. Section 510.210 is amended by revising paragraph (b) to read as
follows:
Sec. 510.210 Determination of the episode.
* * * * *
(b) Cancellation of an episode. The episode is canceled and is not
included in the determination of NPRA as specified in Sec. 510.305 if
any of the following occur:
(1) The beneficiary does any of the following during the episode:
(i) Ceases to meet any criterion listed in Sec. 510.205.
(ii) Is readmitted to any participant hospital for another anchor
hospitalization.
(iii) Initiates an LEJR episode under BPCI.
(iv) Dies.
(2) For performance year 3, the participant hospital did not submit
a participation election letter that was accepted by CMS to continue
participation in the model.
0
7. Section 510.300 is amended by revising paragraph (b)(6) to read as
follows:
Sec. 510.300 Determination of quality-adjusted episode target prices.
* * * * *
(b) * * *
(6) Exclusion of incentive programs and add-on payments under
existing Medicare payment systems. Certain incentive programs and add-
on payments are excluded from historical episode payments by using,
with certain modifications, the CMS Price (Payment) Standardization
Detailed Methodology used for the Medicare spending per beneficiary
measure in the Hospital Value-Based Purchasing Program.
* * * * *
0
8. Section 510.305 is amended by revising paragraph (d)(1) to read as
follows:
Sec. 510.305 Determination of the NPRA and reconciliation process.
* * * * *
(d) * * *
(1) Beginning 2 months after the end of each performance year, CMS
does all of the following:
(i) Performs a reconciliation calculation to establish an NPRA for
each participant hospital.
(ii) For participant hospitals that experience a reorganization
event in which one or more hospitals reorganize under the CCN of a
participant hospital performs--
(A) Separate reconciliation calculations (during both initial and
subsequent reconciliations for a performance year) for each predecessor
participant hospital for episodes where anchor hospitalization
admission occurred before the effective date of the reorganization
event; and
(B) Reconciliation calculations (during both initial and subsequent
reconciliations for a performance year) for each new or surviving
participant hospital for episodes where the anchor hospitalization
admission occurred on or after the effective date of the reorganization
event.
* * * * *
[[Page 39333]]
0
9. Section 510.410 is amended by adding paragraph (b)(1)(i)(G) to read
as follows:
Sec. 510.410 Compliance enforcement.
* * * * *
(b) * * *
(1) * * *
(i) * * *
(G) Failing to participate in CJR model-related evaluation
activities conducted by CMS or its contractors or both.
* * * * *
0
10. Section 510.605 is amended by revising paragraph (c)(2) to read as
follows:
Sec. 510.65 Waiver of certain telehealth requirements.
* * * * *
(c) * * *
(2) CMS waives the payment requirements under section 1834(m)(2)(B)
of the Act to allow the distant site payment for telehealth home visit
HCPCS codes unique to this model.
* * * * *
PART 512--[REMOVED AND RESERVED]
0
11. Part 512, as added January 3, 2017 (82 FR 180), delayed until
October 1, 2017, on March 21, 2017 (82 FR 14464), further delayed until
January 1, 2018, on May 19, 2017 (82 FR 22895), is removed and
reserved.
Dated: August 10, 2017.
Seema Verma,
Administrator, Centers for Medicare & Medicaid Services.
Dated: August 11, 2017.
Thomas E. Price,
Secretary, Department of Health and Human Services.
[FR Doc. 2017-17446 Filed 8-15-17; 4:15 pm]
BILLING CODE 4120-01-P