CMS Considers Including ASCs in Bundled Payment Models
Surgery centers can submit comments until the end of June
BY ALEX TAIRA | JUNE 2020
The deadline to submit comments on how to design a joint replacement model that incorporates ASCs as participants in the Comprehensive Care for Joint Replacement (CJR) bundled payment model is approaching fast. Interested parties may submit comments until 5:00 pm ET on June 23.
The Centers for Medicare & Medicaid Services (CMS) released a proposed rule on February 20, 2020, with a number of updates to the CJR bundled payment model. Among the updates was a request for comments on a new lower extremity joint replacement (LEJR) model that would include ASCs. While private payers have already implemented numerous bundled payment models incorporating ASCs, this is the first indication that Medicare might be considering a non-fee-for-service (FFS) payment arrangement in the ASC space.
Bundled Payment Background
In a bundled payment, the payer provides a single, comprehensive payment designed to cover all care and treatment for a discrete episode of care. The episode is usually defined by a specific time period, and the single, all-encompassing payment is designed to promote alignment between all the stakeholders involved with delivering care (i.e., facilities, physicians, post-acute providers, etc.). Rather than being paid separately, the single payment means that all stakeholders have financial incentive to coordinate and deliver the most efficient, high-quality care possible. If they are able to consistently perform the episode of care for less than the bundled payment, they are rewarded by keeping the remaining amount. If the providers are uncoordinated or patients experience adverse events, the providers would lose money by delivering additional care for no additional reimbursement.
CMS began implementing bundled payment models after the passage of the Patient Protection and Affordable Care Act (ACA), which directed the agency to establish a voluntary pilot program. This program, the Bundled Payment for Care Improvement (BPCI) initiative, began in 2013, with the first phase of the model focused on inpatient stays at acute care hospitals. Later phases of the model incorporated more advanced pricing methodology and extended the episode of care to post-acute settings such as skilled nursing and inpatient rehabilitation.
CMS introduced the CJR model in April 2016 and took a step farther than BPCI by making participation mandatory for hospitals within certain metropolitan statistical areas. For approximately 800 hospitals, a 90-day bundled payment episode would automatically be triggered by discharge under a major joint replacement diagnosis-related group. In 2017, in response to opposition to the mandatory participation structure, the new administration reduced the number of mandatory metropolitan statistical areas from 67 to 34.