Advisor Live: Proposed Episode Payment Models for AMI, CABG, and Hip and Femur Fractures

© 2016 Premier Inc.
Advisor Live®
Advancing Care Coordination Through
Episode Payment Models
Proposed Rule
Aug.10, 2016
@PremierHA
#AdvisorLive
Mark Hiller, MBA, Vice President, Innovative Solutions, Premier Inc.
Danielle Lloyd, MPH, Vice President, Policy and Advocacy, Deputy
Director, DC Office, Premier Inc.
Aisha Pittman, MPH, Director, Quality Policy and Analysis, Premier Inc.

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Mark Hiller, Vice President, Innovative
Solutions, Premier Inc.
Danielle Lloyd, VP, Policy and Advocacy,
Deputy Director, DC Office, Premier Inc.
Aisha Pittman, Director, Quality Policy and
Analysis, Premier Inc.
Faculty

Agenda
5
• Applicable Hospitals
• Applicable Beneficiaries
• Episode Definitions
• Payment Methodology
• Quality Performance
• Reconciliation
• Gainsharing
• Appeal Procedures
• Data Sharing
• Payment and Legal Waivers
• Cardiac Rehab Incentive Payment

Released July 25, published on August 2, Federal Register
Establishes 3 new bundled payment models for AMI, CABG, and
Surgical Hip/Femur Fracture Treatment (SHFFT)
• All Parts A & B services from hospital admission through 90-days post discharge
• Mandatory model in select geographic areas
• AMI and CABG: 98 MSAs (TBD)
• SHFFT: Same 67 regions as CJR
• Requires 3% discount, discount lowered based on “good” or “excellent” quality
performance e
• Requires two-sided risk starting year 2 with stop loss/gain
• Model runs from July 1, 2017- December 31, 2021
Modifies Comprehensive Care for Joint Replacement (CJR)
Creates a track in all models to meet CEHRT requirements in order to
be considered an Advanced APM under MACRA
Creates the Cardiac Rehabilitation Incentive Payment Model
• Provides incentive payments for coordination or rehabilitation services for heart
attach and bypass patients
• Available to 45 MSAs within AMI/CABG models and 45 MSAs outside of
AMI/CABG
Comments due October 3, 2016
Proposed Rule

Annual Medicare spending for all EPM episodes
Admission
Discharge
90 Days
All Medicare Part A & Part B fee-for-service payments
Target price ≈ 3% blended discount of historical hospital costs/broader geographic region
Triggers: CJR: Lower extremity joint replacement - MS-DRG 469/470
EPM-SHFFT: Surgical hip and femur fracture- MS-DRG 480-482
EPM-AMI: AMI w/o revascularization/PCI- MS-DRG 280-282/246-251;ICD-10 CM of AMI
EPM-CABG: Coronary Artery Bypass Graft- MS-DRG 231-236
EpisodeReconciliationpayments
Below spending
target
Above spending
target
$$$$$$$$$$$$$$$ Hospital repays Medicare $$$$$$$$$$$$$$$
$$$$$$$$$$$$$$$ Reconciliation payment to hospital $$$$$$$$$$$$$$$
Quality Composite Score is Adequate, Good, or Excellent
CJR/SHFFT: Complications, Patient Experience, Patient-Reported Outcomes (voluntary)
CABG: Mortality, Patient Experience
AMI: Mortality, Excess Days, Patient Experience, Mortality eMeasure (voluntary)
Current and Proposed Episode Payment Models

CMS proposed rule for the Episode Payment Models
• Comments due 60 days from the date of display (October 3, 2016)
1. Go to proposed rule
2. Click “Submit a Formal Comment”, the green button on the right-
hand side of the page below the title.
OR
1. Go to http://www.regulations.gov
2. Type “CMS-5519-P” into the search box
3. Find “Medicare Program: Advancing Care Coordination Through
Episode Payment Models (EPMs); Cardiac Rehabilitation
Incentive Payment Model; and Changes to the Comprehensive
Care for Joint Replacement Model (CJR)
4. Click on “Comment Now”, the blue button to the right of the title.
EPM Proposed Rule: How to Submit a Comment

EPM Clinical Definitions
Proposed rule includes three new EPMs
• Patients who receive medical therapy but no revascularization (MS DRGs 280-282) and includes
discharges for Percutaneous Coronary Intervention (PCI) (MS DRGs 246-251)
• CMS proposed to adjust target prices based on complexity of treating a heart attack
• Excludes intracardiac procedures
Acute Myocardial Infarction (AMI)
• Patients discharged with MS-DRGs 231-236
• CMS proposed to adjust target prices based on complexity of providing bypass surgery
• Including beneficiaries undergoing elective CABG in the CABG model as well as beneficiaries with
AMI who have a CABG during their initial AMI anchor hospitalization.
Coronary Artery Bypass Graft (CABG)
• Patients discharged with MS-DRGs 480-482
• In conjunction with the existing CJR model (DRGs 469-470)
Surgical Hip/Femur Fracture Treatment (SHFFT)

PY 1
July 1, 2017
to December
31, 2017
PY 2
January 1,
2018 to
December
31, 2018
PY 3
January 1,
2019 to
December
31, 2019
PY 4
January 1,
2020 to
December
31, 2020
PY 5
January 1,
2021 to
December
31, 2021
EPM Performance Years
EPM program runs for a total of five performance years –
Starting on July 1, 2017 through December 31, 2021.
Similar to CJR – EPM episodes that would begin in a given
calendar year may be captured in the following performance year
due to some EPM episodes ending after December 31st of a given
calendar year
• Example: EPM Episodes beginning in December 2017 and ending in March 2018
(90-day episodes), would be part of Performance Year 2.

Target price is based on a 3% discount and is lowered based on
“good” or “excellent” quality performance
Target prices are adjusted for complexity (e.g. MS-DRG, timeframe,
and episode service overlap)
Updated every other year
Phased in risk: No downside risk for Model Year 1, but risk begins
with EPM episodes that begin in 2nd Quarter of PY 2 (April-June
2018)
Payment Methodology – Phased-in Risk
Model Year Date Range Repayments (i.e. Risk) Stop Loss/Stop Gain*
Year 1 7/1/17 – 12/31/17 • No repayments • Upside only of 5%
Year 2 CY 2018 • No repayments in 1st quarter
• 2nd, 3rd, and 4th quarters a
maximum required discount
of 2%
• Upside/Downside of 5%
Year 3 CY 2019 • Maximum required discount
of 2%.
Year 4 and 5 CY 2020 – CY 2021 • Maximum required discount
of 3%.
*Stop-loss thresholds for certain hospitals, including rural and sole-community hospitals are 3% for PY2 (Downside Risk) and 5% for PY3-PY5.

Propose to exclude:
• Drugs that are paid outside of the MS-DRGs included in
the EPM episode definition, specifically hemophilia clotting
factors
• Technology add-on payments (excluded from historical
data and actual EPM episode payments and applies to
anchor hospitalization and related readmissions)
• OPPS transitional pass-through payments for medical
devices
• Readmissions for oncology, trauma medical admissions,
surgery for chronic conditions unrelated to EPM episode
(same as CJR)
Propose to identify unrelated Part B services and
readmissions based on BPCI Model 2 “Part B
Exclusions List”
Included EPMs may also include certain Per
Member/Per Month (PMPM) payments
Payment Methodology – Excluded/Included Payments

Blended Target Pricing
100%
regional
Year
4 & 5
1/3
hospital
2/3
regional
Year
3
2/3
hospital
1/3
regional
Year
1 & 2
Target rates begin as a combination of hospital-specific and regional (US
census region) historical payments and transition to regional-only rates

Baseline is comprised of 3 years historical data –
January 1, 2013 through December 31, 2015
• NOTE: Separate pricing for January 1st through September 30th vs.
October 1st through December 31st due to Medicare payment system
update timeframe differences.
• Episode price periods apply to episodes that initiate during those periods
except Performance Year 5.
• Prices will be communicated prior to beginning of performance periods.
• Prices will be set for each clinical definition.
Treatment of reconciliation and Medicare repayment:
• EPMs: Include both reconciliation payments and Medicare repayments
when calculating historical EPM-episode payments to update EPM-
episode benchmark and quality-adjusted target prices
 Plan to also include BPCI NPRA amounts
 PROPOSING TO CHANGE CJR METHODOLOGY TO MATCH
Price Setting

Reconciliation Timeline
Proposed Timeframe for Reconciliation for EPMs
EPM Performance
Year
EPM Performance
Period
Reconciliation
Claims Submitted
By
NPRA
Calculation
Second
Reconciliation, ACO
Overlap, and Post-
Episode Spending
Calculations
Calculation Amounts
Included in
Reconciliation
Payment and
Repayment Amounts
Year 1*
Episodes beginning
on or after July 1,
2016 and ending
through December
31, 2017
March 1, 2018 Q2 2018 March 1, 2019 Q2 2019
Year 2
Episodes ending
January 1, 2018
through December
31, 2018
March 1, 2019 Q2 2019 March 1, 2020 Q2 2020
Year 3
Episodes ending
January 1, 2019
through December
31, 2019
March 1, 2020 Q2 2020 March 2, 2021 Q2 2021
Year 4
Episodes ending
January 1, 2020
through December
31, 2020
March 2, 2021 Q2 2021 March 1, 2021 Q2 2021
Year 5
Episodes ending
January 1, 2021
through December
31, 2021
March 1, 2022 Q2 2022 March 1, 2023 Q2 2023
* Note that the reconciliation for Year 1 would not include repayment responsibility from EPM participants.

In contrast to the CJR model, AMI episodes will have price
adjustments in the cases of certain transfers (i.e. “chained
hospitalizations”) and readmissions.
Proration – Use same methodology as CJR for prorating payments
for services that extend beyond 90 day post discharge
High cost episodes – Outlier ceilings based on regional data and
by MS-DRG
“CABG Readmission AMI Model episode Benchmark Price" –
Episode benchmark price assigned to certain AMI model episodes
with price MS-DRG 280-282 or 246-251 and with a readmission for
MS-DRG 231-236
"Price MS-DRG" – For AMI model episodes with a chained anchor
hospitalization, the price MS-DRG is the MS-DRG assigned to the
AMI model episode according to the hierarchy outlined in the
following table on the following slide.
EPM Pricing Scenarios

Scenario
“Price
MS-DRG”
Anchor Price
MS-DRG
Post-Acute Care
Price MS-DRG
AMI (Single Hospitalization– Not Chained):
• AMI AMI
AMI (Chained Hospitalization of):
• AMI PCI
• CABG CABG CABG with AMI
AMI with CABG Readmission:
• CABG (without chained
hospitalization)
AMI+ CABG
• CABG (with chained
hospitalization that is not a
CABG)
AMI+ CABG
CABG (Single Hospitalization – Not Chained):
• CABG with AMI CABG CABG with AMI
• CABG without AMI CABG CABG without AMI
SHFFT:
• Without total joint replacement SHFFT
• With total joint replacement CJR
EPM Pricing Scenarios (Cont.)

Beneficiaries must meet all the following criteria:
• Enrolled in Medicare Part A and Part B.
• Eligible for Medicare not on the basis of end-stage renal disease (ESRD).
• Not enrolled in any managed care plan (for example, Medicare Advantage, Health
Care Prepayment Plans, cost-based health maintenance organizations)
• Not covered under a United Mine Workers of America health plan, which provides
health care benefits for retired mine workers.
• Have Medicare as their primary payer.
• Not aligned to an ACO in the Next Generation ACO model or an ACO in a track of
the Comprehensive ESRD Care Initiative incorporating downside risk for financial
losses.
• Not already in any BPCI model episode.
• Not already in an AMI, SHFFT, CABG or CJR model episode with an episode
definition that does not exclude the MS-DRG that would be the anchor MS-DRG
under the applicable EPM.
• Not under the care of an attending or operating physician, as designated on the
inpatient hospital claim, who is a member of a physician group practice that
initiates BPCI Model 2 episodes at the EPM participant for the MS-DRG that
would be the anchor MS-DRG under the EPM.
Beneficiary Inclusions

Not aligned to the following ACO types:
• Next Generation ACO model
• Comprehensive ESRD Care Initiative track, incorporating downside risk
Beneficiary death during an anchor hospitalization of EPM
episodes would cancel the EPM.
• NOTE: This is different than CJR where beneficiary death at any point
during the episode cancels the episode.
EPM episode begins with initial hospitalization – Not prior to
admission
• NOTE: The episode does NOT begin three days prior, only that services
provided in the three days prior would be included in the MS-DRG
payment would be included (72-hour rule).
• Example: This is important as transfers from another hospital’s ED
within the three day period would not be included.
Beneficiary/Other Exclusions

Since many hospitals do not provide PCI or CABG services, CMS has created a
chained hospitalization pricing model. For example:
Payment Methodology – Special Transfer Rules
Scenario 1 Scenario 2
Scenario 3 Scenario 4
Initial IP Hospitalization
(NOT in AMI/CABG EPM)
Transfer
2nd IP Hospitalization*
(AMI/CABG EPM)
Result: Episode will initiate with participating EPM Hospital
2nd IP Hospitalization
(NOT in AMI/CABG EPM)
Transfer
Initial IP Hospitalization*
(AMI/CABG EPM)
Result: Episode will initiate with initial EPM Hospital
NOTE: Episode would be cancelled if the discharge MS-DRG from the
2nd hospital is not an AMI/CABG EPM MS-DRG
Initial IP Hospitalization*
(AMI/CABG EPM)
Transfer
(AMI/CABG EPM)
Result: Initial EPM Hospital will retain responsibility for EPM
episode regardless of transfer
NOTE: Episode would be cancelled if the discharge MS-DRG from the
2nd hospital is not an AMI/CABG EPM MS-DRG
CABG does NOT
cancel an AMI Episode
Result: There would be an AMI pricing adjustment by
paying the AMI Model participant based on a MS-DRG price
that is different from the anchor MS-DRG to reflect
Medicare payment for the CABG
*Day of Anchor Discharge = Day 1 of Post-Acute 90-day Period**
**However, in AMI chained hospitalizations, Day 1 would be day of discharge from transfer (e.g. 2nd hospital)
Initial IP Hospitalization
(AMI EPM)
(CABG EPM)

BPCI: “CMS believes that BPCI supports the design of
the proposed EPM models.”
• BPCI takes precedence – whether hospital, PGP or other BPCI
Awardee
• Precedence is based on specific episode overlap – not just
overlap at the program level
• Initiation of a BPCI episode would cancel the EPM
Precedence Rules
BPCI
Hospital/PGP
(Model 2 – CABG)
EPM
MSA
?
YES
NO
Included
for AMI
No
Changes
Scenario 1 – AMI/CABG
BPCI
Hospital/PGP
(Model 2 – LEJR)
CJR
MSA
?
YES
NO
Included
for SHFFT
No
Changes
Scenario 2 – SHFFT

Creates a track in each model that would potentially
qualify for the Advanced Alternative Payment (APM)
bonus under MACRA in CY 2019 (payment year 2021).
Track 1 – Qualifies organization for APMs:
 Participants must use and attest to Certified Electronic Health
Record Technology (CEHRT)
 Target price with 3% discount AND 5% aggregate risk in Year 2
 Physician will have to be in a Sharing Agreement with an EPM
participant (a.k.a. hospital)
Track 2 – Does not qualify as APM
NOTE: CMS proposed to build upon the Bundled Payment for Care
Improvement (BPCI) initiative by implementing a new voluntary
bundled payment model for CY 2018 that would be designed to meet
the criteria to be an Advanced APM under MACRA.
Advanced APM Tracks

Required discount factor of 3%
Hospitals with “good” or “excellent” quality are awarded a
quality incentive payment (1 or 1.5%) which reduces the
discount factor
Hospitals with “acceptable”, “good”, or “excellent” quality
are eligible for to receive a reconciliation payment if
actual spending is less than target spending
Discount Factor Depends on Quality Performance
*discount factor lowered due to quality incentive payment
Year 1 Discount
Factor %
Eligible for
Reconciliation
Repayment %
Below acceptable 3.0 No No Repayment
in Year 1Acceptable 3.0 Yes
Good 2.0* Yes
Excellent 1.5* Yes

Discount Factor Depends on Quality Performance
Years 4/5 Discount
Factor %
Eligible for
Reconciliation
Repayment %
Below acceptable 3.0 No 3.0
Acceptable 3.0 Yes 3.0
Good 2.0* Yes 2.0
Excellent 1.5* Yes 1.5
Years 2/3 Discount
Factor %
Eligible for
Reconciliation
Repayment %
Below acceptable 3.0 No 2.0
Acceptable 3.0 Yes 2.0
Good 2.0* Yes 1.0
Excellent 1.5* Yes 0.5
*discount factor lowered due to quality incentive payment

EPM Proposed Quality Measures:
EPM Quality Measures
• Mortality (NQF
#0230)
• Excess Days,
HCAHPS (NQF
# 0166)
• Mortality
eMeasure
(voluntary)
(NQF #2473
• Mortality (NQF
#2558)
• HCAHPS
(NQF #0166)
• Complications
for THA/TKA
(NQF #1550)
• HCAHPS (NQF
#0166)
• Patient-
Reported
Outcomes
(voluntary)
AMI CABG SHFFT

Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate
(RSMR) Following Acute Myocardial Infarction (NQF #0230) (MORT-
30-AMI)
• 3 year rolling performance period: July 1, 2014- June 30, 2017
• Cohort may be slightly different from IQR cohort
• Not publicly reported if fewer than 25 cases
Excess Days in Acute Care after Hospitalization for AMI (AMI Excess
Days)
• 3 year rolling performance period: July 1, 2014- June 30, 2017
• Cohort includes all hospitals in the model and may be slightly different
from IQR cohort
• Not publicly reported if fewer than 25 cases; hospital-specific reports will
be distributed
HCAHPS Survey (NQF #0166)
• 4 consecutive quarters of survey data
• Data submission the same as IQR
Voluntary Hybrid Hospital 30-Day, All-Cause, Risk-Standardized
Mortality Rate Following Acute Myocardial Infarction (AMI)
Hospitalization (NQF #2473) (Hybrid AMI Mortality) data submission
Measures- AMI

Combines claims and EHR data to calculate a risk-standardized mortality rate
following AMI
Cohort identical to current measure, enhanced with EHR data
• Five clinical data elements included in risk adjustment
• Age
• Heart Rate within 2 hours
• Systolic Blood Pressure within 2 hours
• Troponin within 24 hours
• Creatine within 24 hours
• Intended to reflect clinical status when first presenting for AMI
• Collecting six additional variables
• CCN
• HIC
• Date of Birth
• Gender
• Admission Date
• Discharge Date
• Seek comment on submission mechanism: QRDA, spreadsheet, or both for year 1; QRDA for
subsequent years
Successful submission
• Year 1: 50% of qualifying AMI hospitalizations; Year 2-5: 90%
• All additional elements (able to indicate troponin test was not performed)
• Submit within 60 days of end of data collection period
Not publicly reported, hospitals will receive hospital-specific reports
AMI- Voluntary Data Submission for Hybrid AMI Mortality
Measure

Measure Weight Max Points (20) Scoring
AMI Mortality 50% 10
1.0 improvement point*
90th percentile and above:10
80th- 90th percentile: 9.25
Below 30th percentile: 0
AMI Excess Days 20% 4
0.4 improvement points*
90th percentile and above: 4
HCAHPS 20% 4
0.4 improvement points*
Same as above
Hybrid AMI
Mortality voluntary
10% 2 2 points for successful submission
Quality Composite Scoring-AMI
* Improvement points awarded for any year-over-year improvement in a participant’s own measure point estimates if the
participant falls into the top 10 percent of participants based on the national distribution of measure improvement.

Hospital 30-Day, All-Cause, Risk-Standardized
Mortality Rate (RSMR) Following Coronary
Artery Bypass Graft (CABG) Surgery (NQF
#2558) (MORT-30-CABG)
• 3 year rolling performance period: July 1, 2014- June
30, 2017
HCAHPS Survey (NQF #0166)
Measures- CABG

Measure Weight Max Points (20) Scoring
CABG Mortality 75% 15
1.0 improvement point*
HCAHPS 25% 5
0.5 improvement
points*
Quality Composite Scoring-CABG
* Improvement points awarded for any year-over-year improvement in a participant’s own
measure point estimates if the participant falls into the top 10 percent of participants based on
the national distribution of measure improvement.

Hospital-level RSCR (complications) following
elective primary THA and/or TKA (NQF #1550)
• 3 year rolling performance period: April 1, 2014-
March 31, 2017
HCAHPS Survey measure
Considered an alternative approach that would
only use HCAPS
Measures- SHFFT

Hospital-Level Performance Measure(s) of Patient-Reported
Outcomes Following Elective Primary THA or TKA measure or both
• In development, voluntary data submission will help continue development
• Pre- and post-operative data elements (examples):
• Demographic info (age, DOB, admission date, discharge date, procedure date)
• PROMIS Global or VR-12
• Knee-specific PROM instrument (e.g. HOOS JR, HOOS Pain Subscale, HOOS
Function)
• Hip-specific PROM Instrument (e.g., VR-12, PROMIS, HOOS Jr, HOOS Function)
Reporting Period:
• Year 1: Pre-operative data (10-month period)
• Year 2: Post-operative data for prior year (10-months) and pre-operative data for
current year (12-month period)
• Years 3 and beyond: Pre-operative and post-operative data for a 12-month period
Successful Submission
• All required data elements
• Year 1: 60% of patients; Year 2: 70% of patients. Year 3-5: 80% of patients
• Voluntary submission must occur within 60 days of the end of the most recent 12-
month period
SHFFT- Voluntary Data Submission for Patient-Reported
Outcome Data

Measure Weight Max Points
(20)
Scoring
Hospital-level RSCR
(complications)
following elective
primary THA and/or
TKA
50% 10
1.0
improvement
point*
HCAHPS Survey 40% 8
0.8
improvement
points*
90th percentile and above: 8
THA/TKA voluntary
PRO data
10% 2 2 points for successful
submission
Quality Composite Scoring- SHFFT
* Improvement points awarded for substantial improvement (2 deciles or more in
comparison to national average) from prior years performance.

Category Discount
Factor %
AMI CABG SHHFT/CJR
Below
acceptable
3.0 Less than 3.6 Less than 2.8 Less than 5.0
Acceptable 3.0 3.6 to less
than 6.9
2.8 to less
than 4.8
5.0 to less
than 6.9
Good 2.0 6.9 to less
than 14.8
4.8 to less
than 17.5
6.9 to less
than 15.0
Excellent 1.5 Above 14.8 Above 17.5 Above 15.0
Quality Composite Score Categories

Hip and Femur Fracture
• Claims-based or hybrid risk-standardized hospital-
level mortality, complication, and/or readmission
measures for patients with hip fracture
• Patient-reported outcome data-based measures of
functional status, symptom burden, number of days at
home and/or return to home and/or independent living
suitable for patients with hip fractures and/or patients
undergoing total hip or knee arthroplasty
Measures attributable to post-acute care facilities
and clinicians
Potential Future Measures

Hospitals included in distribution is all that meet
minimum case thresholds rather than all
Changes aligning with SHFFT
• Improvement points for an increase of at least 2
(rather than 3) deciles on the performance percentile
scare compared to prior years performance
• Categorization of composite scores
• Capping maximum score at 20 points, rather than 21.8
• Publicly report successful submission (rather than all
submissions) of voluntary measure data
• Remove Pain Management from calculation of
HCAHPS score
CJR Quality Changes

Hospitals may have “sharing
arrangements” with
“collaborators” to share:
• reconciliation payments,
• internal cost savings, and
• alignment payments.
Must have written policies on
selecting collaborators that
include quality metrics and
do not include criteria
directly or indirectly based
on volume or value of
referrals in the past or
anticipated.
Gainsharing
Collaborators may
include:
• Physician and non-physician
practitioners (NPP)
• Home health agencies
(HHA)
• Skilled nursing facilities
(SNF)
• Long term care hospitals
(LTCH)
• Physician Group Practices
(PGP)
• Inpatient rehabilitation
facilities (IRF)
• Provider or supplier of
outpatient therapy services
• Hospital/CAH*
• ACO*
*new

Must be voluntary, without penalty for non-participation,
associated with quality scores and paid once a year
Must comply with §512: beneficiary notification, access to
records, record retention, and participation in evaluation,
monitoring, compliance and enforcement activities
Collaborators other than PGPs/ACO must furnish
services during episode to be eligible for incentives
• PGPs/ACOs must assist with clinical activities and have at least
one physician/NPP provide services to an applicable beneficiary
Methodology may vary payments based on relative
contribution of collaborators activities
Cap on individual physicians and NPPs is 50% of FFS
payments made in relation to applicable beneficiaries
Gainsharing (continued)

Financial Responsibility
As only Episode Initiators, risk accrues solely to the hospital
Participant hospitals may assign a portion of the two-sided
risk to “collaborators”
• CMS will solely interact with the hospital
• The hospital is responsible for interacting with collaborators to pay or
recoup funds
Hospitals are required to retain 50% of downside risk
Hospitals cannot share more than 25% of repayment
responsibility with any one collaborator other than ACOs,
which may absorb up to 50% of the risk
An alignment payment is a collaborator payment back to
the hospital as a result of shared risk arrangements

Dated, written agreement memorializing:
purpose and scope of the sharing arrangement.
identities and obligations of the parties, including specified
EPM activities and other services to be performed by the
parties under the sharing arrangement.
management and staffing information, including personnel
primarily responsible for EPM activities.
financial terms for payment, including the following:
• Eligibility criteria for a gainsharing payment.
• Eligibility criteria for an alignment payment.
• Frequency of gainsharing or alignment payment.
• Methodology for determining the amount of a gainsharing payment
that is substantially based on quality of EPM activities.
• Methodology for determining amount of an alignment payment.
Must not reduce or limit medically necessary services
Sharing Arrangements

EPM participant must:
Document the sharing arrangement contemporaneously with the
establishment of the arrangement;
Maintain accurate current and historical lists of all EPM collaborators,
including EPM collaborator names and addresses; update such lists
on at least a quarterly basis; and publicly report current/historical lists
collaborators on a webpage on the EPM participant's website; and
Maintain and require each EPM collaborator to maintain
contemporaneous documentation with respect to the payment or
receipt of any gainsharing/alignment payment that includes--
• Nature of the payment (gainsharing payment or alignment payment);
• Identity of the parties making and receiving the payment;
• Date of the payment;
• Amount of the payment;
• Date and amount of any recoupment of all or a portion of an EPM collaborator's
gainsharing payment; and
• Explanation for each recoupment, such as whether the EPM collaborator received
a gainsharing payment that contained funds derived from a CMS overpayment on
a reconciliation report, or was based on the submission of false or fraudulent
data.
Documentation

EPM participant must keep records for the
following:
• Its process for determining and verifying its potential
and current EPM collaborators' Medicare participation.
• Its plan to track internal cost savings.
• Information on the accounting systems used to track
internal cost savings;
• A description of current health information technology,
including systems to track reconciliation payments and
internal cost savings; and
• Its plan to track gainsharing/alignment payments.
Collaborator to retain and provide access to, the
required documentation in accordance with §
512.110.
Documentation (continued)

Summary reports on episodes during the baseline (Jan. 1,
2013-Dec. 31, 2015) and performance periods
Includes all expenditures and claims for an EPM episode
for all care covered under Medicare Parts A and B within
the 90 days after discharge for those beneficiaries for
applicable anchor diagnosis billed by participant
Summary reports will contain at least inpatient, outpatient,
SNF, HHA, hospice, carrier/Part B and DME services
May request raw claims data including services furnished
by the participant and other entities during the episode
For both formats, quarterly files and excludes substance
use related patient records
Aggregate expenditure data on US Census Divisions
through 90-day episode
Data Sharing- Beneficiary Level Data

Provides certain waivers of Fraud and Abuse
Laws
• For gainsharing and alignment payments the model
waives:
• Federal Anti-kickback statute
• Physician self-referral prohibitions
• Civil monetary penalties (inapplicable due to MACRA law)
• For beneficiary incentives furnished to CJR
beneficiaries during a CJR episode of care provided the
program requirements are met, the model waives:
• Beneficiary inducements CMP
• Federal Anti-kickback statute
Legal Waivers

Permits participating hospitals (not collaborators) to
provide “in-kind patient engagement incentives” for free
or below fair market value subject to the following
conditions:
• The incentive must be provided during an episode of care.
• The item or service provided must be reasonably connected to
the beneficiary's medical care during an episode and engage the
beneficiary in better managing his or her own health.
• The item or service must be a preventive care item or service or
advance one of the following clinical goals:
• Beneficiary adherence to drug regimens.
• Beneficiary adherence to a care plan.
• Reduction of readmissions and complications resulting from LEJR
procedures.
• Management of chronic diseases and conditions that may be
affected by the LEJR procedure.
Beneficiary Incentives

• The incentive must not be tied to the receipt of items
or services from a particular provider or supplier.
• The incentive must not be tied to the receipt of items
or services outside the episode of care.
• The item or service may only be provided by a
participating hospital directly or through an agent who
is under the hospital’s control and direction. In the final
rule, CMS notes that if a reasonable beneficiary would
perceive the item or service as being from the agent
rather than the hospital, the incentive would not be
treated as provided by the hospital and thus is not
eligible for protection under this provision.
• The cost of the item or service may not be shifted to
another federal health care program.
Beneficiary Incentives (continued)

Must maintain contemporaneous documentation of
beneficiary incentives that exceed $25 in value
Must include the date the incentive is provided as well as
the identity of the beneficiary to whom it was provided.
May provide items of technology if the value of the
technology does not exceed $1,000 for any one
beneficiary.
• hospital must retain ownership of the technology where the cost
of the technology exceeds $100
• hospital must retrieve the technology at end of the episode and
maintain documentation of the date of retrieval
• the agency will deem “documented, diligent, good faith attempts
to retrieve items of technology” to meet the retrieval requirement
Beneficiary Incentive (continued)

Payment Waivers for EPMs
Skilled Nursing
Facility
• Waives the SNF 3-
day rule beginning
in PY2 for AMI only
• SNF must be rated
3-stars or higher to
apply waiver
• Premature
discharges to SNF
are not allowed
• Freedom of choice
for SNF without
patient steering
• Hospital liable if
waiver mis-used
• Hospital and
beneficiary held
harmless if
beneficiary eligibility
changes for CJR
Home Visits
• Waives the direct
supervision rule for
“incident to”
services
• Licensed clinical
staff to furnish visit
• Applies to
beneficiaries that
don’t qualify for
home health
coverage
• Waives 90-day post-
operative global
surgical period for
up to 9 visits (13 for
AMI)
• Will bill HCPCS G
codes (~$50)
Telehealth
• Waives geographic
site and originating
site requirements
• Cannot substitute
for in-person home
health services paid
under Home Health
PPS
• Must be furnished in
accordance with all
other coverage and
payment criteria
• Will bill HCPCS G
codes

GOAL: test the cost and quality effects of providing
explicit financial incentives to encourage care
coordination and increased CR use during 90 days after
hospitalization for beneficiaries treated for AMI or CABG
Cardiac rehab (CR)—physician-supervised program that
furnishes prescribed exercise, cardiac risk factor
modification, psychological and outcomes assessments.
• 2 one-hour sessions per day for up to 36 sessions over 36 weeks
with option of additional 36 sessions if MAC approved
Intensive cardiac rehab (ICR)—physician-supervised
program that furnishes cardiac rehab and has shown, in
peer-reviewed published research, that improves
patient’s cardiovascular disease through specific
outcome measurement
• Limited to 72 one-hour sessions, up to 6 sessions per day, over a
period of up to 18 weeks
Cardiac Rehab for AMI and CABG

Timing—coincides with EPM; July 1, 2017-Dec. 31, 2021
Areas—4 matched groups by MSA: FFS-CR, FFS-non
CR, EPM-CR, and EPM-non CR.
• Will select 45 MSAs from 98 finalized under EMP and another 45
from the remainder of the 294 eligible areas
• Will stratify based on percent starting I/CR, percent completing
I/CR, and number of I/CR providers.
Incentive payments—will go to hospital if any provider/
supplier furnishes I/CR to applicable beneficiaries
• $25 per I/CR for up to 11 services; $175 per I/CR for 12 or more
services for rest of the episode
• Paid once a aggregate amount once per performance year
• Will not be part of EPM reconciliation; cannot be in gainsharing
Waiver— allows non-physician practitioners to supervise,
prescribe exercise and establish, review, and sign plans
• Will allow some beneficiary incentives such as transportation
Cardiac Rehab for AMI and CABG

HCPCS Code Descriptor
93797
Physician services for outpatient cardiac
rehabilitation; without continuous ECG monitoring
(per session)
93798
Physician services for outpatient cardiac
rehabilitation; with continuous ECG monitoring
(per session)
G0422
Intensive cardiac rehabilitation; with or without
continuous ECG monitoring with exercise, per
session
G0423
Intensive cardiac rehabilitation; with or without
continuous ECG monitoring; without exercise, per
session
TABLE 37: HCPCS CODES FOR CARDIAC
REHABILITATION AND INTENSIVE CARDIAC
REHABILITATION SERVICES

Due to narrow scope, FFS-CR participants, upon
request, will receive:
• Inpatient claims -- potential admissions for CABG and AMI MS-
DRGs, plus PCI MS-DRGs if paired with an AMI ICD-CM
diagnosis as a principal or secondary code, and
• Carrier and Outpatient claims -- CR/ICR services occurring in
the 90-day period after discharge for treatment of AMI or for
CABG surgery (AMI or CABG “care period”).
Either summary or claims-level format on a running
quarterly basis on data portal.
Participants would receive data for up to the current
quarter and all of the previous quarters going back to
July 1, 2017.
Subsequent data would be released as often as quarterly
and would include up to 6 quarters of prior data.
Cardiac Rehab Data Sharing

Premier detailed summary
Proposed rule
CMS press release
CMS fact sheet
Important Links

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Appendix A
MSA
CJR/SHFF
T Region
AMI/CABG
Eligible Region
Akron, OH Yes Include
Albuquerque, NM Yes Include
Anaheim-Santa Ana-Irvine, CA Yes Include
Asheville, NC Yes Include
Athens-Clarke County, GA Yes Include
Austin-Round Rock, TX Yes Include
Beaumont-Port Arthur, TX Yes Include
Bismarck, ND Yes Include
Cape Girardeau, MO-IL Yes Include
Carson City, NV Yes Include
Charlotte-Concord-Gastonia, NC-SC Yes Include
Cincinnati, OH-KY-IN Yes Include
Columbia, MO Yes Include
Corpus Christi, TX Yes Include
Decatur, IL Yes Include
Denver-Aurora-Lakewood, CO Yes Include
Dothan, AL Yes Include
Durham-Chapel Hill, NC Yes Include
Dutchess County-Putnam County, NY Yes Include
Flint, MI Yes Include
Florence, SC Yes Include
Fort Lauderdale-Pompano Beach-
Deerfield Beach, FL Yes Include
Gainesville, FL Yes Include
Gainesville, GA Yes Include
Greenville, NC Yes Include
Harrisburg-Carlisle, PA Yes Include
Hot Springs, AR Yes Include
MSA
CJR/SHFF
T Region
AMI/CABG Eligible
Region
Indianapolis-Carmel-Anderson, IN Yes Include
Kansas City, MO-KS Yes Include
Killeen-Temple, TX Yes Include
Lincoln, NE Yes Include
Los Angeles-Long Beach-Glendale, CA Yes Include
Lubbock, TX Yes Include
Madison, WI Yes Include
Memphis, TN-MS-AR Yes Include
Miami-Miami Beach-Kendall, FL Yes Include
Milwaukee-Waukesha-West Allis, WI Yes Include
Modesto, CA Yes Include
Monroe, LA Yes Include
Montgomery, AL Yes Include
Naples-Immokalee-Marco Island, FL Yes Include
Nashville-Davidson--Murfreesboro--
Franklin, TN Yes Include
Nassau County-Suffolk County, NY Yes Include
New Haven-Milford, CT Yes Include
New Orleans-Metairie, LA Yes Include
New York-Jersey City-White Plains, NY-
NJ Yes Include
Newark, NJ-PA Yes Include
Norwich-New London, CT Yes Include
Oakland-Hayward-Berkeley, CA Yes Include
Ogden-Clearfield, UT Yes Include
Oklahoma City, OK Yes Include
Potentially “included” in All Models
CJR/SHFFT + potential AMI/CABG

Potentially “included” in All Models (cont.)
MSA
CJR/SHFFT
Region
AMI/CABG
Eligible Region
Pensacola-Ferry Pass-Brent, FL Yes Include
Pittsburgh, PA Yes Include
Port St. Lucie, FL Yes Include
Portland-Vancouver-Hillsboro, OR-WA Yes Include
Provo-Orem, UT Yes Include
Reading, PA Yes Include
Saginaw, MI Yes Include
San Francisco-Redwood City-South San
Francisco, CA Yes Include
San Rafael, CA Yes Include
Seattle-Bellevue-Everett, WA Yes Include
Sebastian-Vero Beach, FL Yes Include
St. Louis, MO-IL Yes Include
Staunton-Waynesboro, VA Yes Include
Tacoma-Lakewood, WA Yes Include
Tampa-St. Petersburg-Clearwater, FL Yes Include
Toledo, OH Yes Include
Topeka, KS Yes Include
Tuscaloosa, AL Yes Include
Tyler, TX Yes Include
West Palm Beach-Boca Raton-Delray
Beach, FL Yes Include
Wichita, KS Yes Include

Potentially “included” AMI/CABG only
MSA
CJR/SHFFT
Region
AMI/CABG
Eligible Region
Abilene, TX No Include
Albany, GA No Include
Alexandria, LA No Include
Allentown-Bethlehem-
Easton, PA-NJ No Include
Altoona, PA No Include
Amarillo, TX No Include
Ames, IA No Include
Anchorage, AK No Include
Ann Arbor, MI No Include
Anniston-Oxford-
Jacksonville, AL No Include
Appleton, WI No Include
Atlanta-Sandy Springs-
Roswell, GA No Include
Atlantic City-Hammonton,
NJ No Include
Auburn-Opelika, AL No Include
Augusta-Richmond County,
GA-SC No Include
Bangor, ME No Include
Barnstable Town, MA No Include
Baton Rouge, LA No Include
Bay City, MI No Include
Beckley, WV No Include
Bellingham, WA No Include
Bend-Redmond, OR No Include
Billings, MT No Include
Birmingham-Hoover, AL No Include
Bloomington, IL No Include
Bloomington, IN No Include
MSA
CJR/SHFF
T Region
AMI/CABG
Eligible Region
Bloomsburg-Berwick, PA No Include
Boise City, ID No Include
Boston, MA No Include
Bridgeport-Stamford-Norwalk, CT No Include
Brownsville-Harlingen, TX No Include
Brunswick, GA No Include
Burlington-South Burlington, VT No Include
Cambridge-Newton-Framingham,
MA No Include
Camden, NJ No Include
Canton-Massillon, OH No Include
Cape Coral-Fort Myers, FL No Include
Carbondale-Marion, IL No Include
Cedar Rapids, IA No Include
Chambersburg-Waynesboro, PA No Include
Champaign-Urbana, IL No Include
Charleston, WV No Include
Charleston-North Charleston, SC No Include
Charlottesville, VA No Include
Chattanooga, TN-GA No Include
Cheyenne, WY No Include
Chicago-Naperville-Arlington
Heights, IL No Include
Chico, CA No Include
Clarksville, TN-KY No Include
Cleveland-Elyria, OH No Include
Coeur d'Alene, ID No Include

MSA
CJR/SHFFT
Region
AMI/CABG
Eligible
Region
College Station-Bryan, TX No Include
Colorado Springs, CO No Include
Columbia, SC No Include
Columbus, GA-AL No Include
Columbus, IN No Include
Corvallis, OR No Include
Crestview-Fort Walton Beach-
Destin, FL No Include
Dallas-Plano-Irving, TX No Include
Daphne-Fairhope-Foley, AL No Include
Davenport-Moline-Rock Island,
IA-IL No Include
Dayton, OH No Include
Deltona-Daytona Beach-
Ormond Beach, FL No Include
Des Moines-West Des Moines,
IA No Include
Detroit-Dearborn-Livonia, MI No Include
Dover, DE No Include
Duluth, MN-WI No Include
Eau Claire, WI No Include
El Paso, TX No Include
Elgin, IL No Include
Elizabethtown-Fort Knox, KY No Include
Elkhart-Goshen, IN No Include
Elmira, NY No Include
Erie, PA No Include
Eugene, OR No Include
Evansville, IN-KY No Include
Fargo, ND-MN No Include
MSA
CJR/SHFF
T Region
AMI/CABG
Eligible
Region
Farmington, NM No Include
Fayetteville, NC No Include
Fayetteville-Springdale-
Rogers, AR-MO No Include
Florence-Muscle Shoals, AL No Include
Fort Collins, CO No Include
Fort Wayne, IN No Include
Fort Worth-Arlington, TX No Include
Fresno, CA No Include
Gadsden, AL No Include
Gary, IN No Include
Grand Forks, ND-MN No Include
Grand Junction, CO No Include
Grand Rapids-Wyoming, MI No Include
Greeley, CO No Include
Green Bay, WI No Include
Greensboro-High Point, NC No Include
Greenville-Anderson-Mauldin,
SC No Include
Gulfport-Biloxi-Pascagoula, MS No Include
Hartford-West Hartford-East
Hartford, CT No Include
Hattiesburg, MS No Include
Hickory-Lenoir-Morganton, NC No Include
Hilton Head Island-Bluffton-
Beaufort, SC No Include
Homosassa Springs, FL No Include
Houma-Thibodaux, LA No Include
Houston-The Woodlands-
Sugar Land, TX No Include

MSA
CJR/SHFFT
Region
AMI/CABG
Eligible
Region
Huntington-Ashland, WV-KY-
OH No Include
Huntsville, AL No Include
Idaho Falls, ID No Include
Iowa City, IA No Include
Jackson, MI No Include
Jackson, MS No Include
Jacksonville, FL No Include
Janesville-Beloit, WI No Include
Jefferson City, MO No Include
Johnstown, PA No Include
Jonesboro, AR No Include
Joplin, MO No Include
Kalamazoo-Portage, MI No Include
Kankakee, IL No Include
Kennewick-Richland, WA No Include
Kingsport-Bristol-Bristol, TN-VA No Include
Knoxville, TN No Include
La Crosse-Onalaska, WI-MN No Include
Lafayette, LA No Include
Lafayette-West Lafayette, IN No Include
Lake Charles, LA No Include
Lake County-Kenosha County,
IL-WI No Include
Lake Havasu City-Kingman, AZ No Include
Lakeland-Winter Haven, FL No Include
Lansing-East Lansing, MI No Include
Las Cruces, NM No Include
MSA
CJR/SHFF
T Region
AMI/CABG
Eligible
Region
Las Vegas-Henderson-Paradise, NV No Include
Lawton, OK No Include
Lewiston-Auburn, ME No Include
Lexington-Fayette, KY No Include
Lima, OH No Include
Little Rock-North Little Rock-Conway, AR No Include
Longview, TX No Include
Louisville/Jefferson County, KY-IN No Include
Lynchburg, VA No Include
Macon, GA No Include
Manchester-Nashua, NH No Include
Mansfield, OH No Include
Medford, OR No Include
Michigan City-La Porte, IN No Include
Midland, MI No Include
Minneapolis-St. Paul-Bloomington, MN-
WI No Include
Missoula, MT No Include
Mobile, AL No Include
Monroe, MI No Include
Montgomery County-Bucks County-
Chester County, PA No Include
Morgantown, WV No Include
Muncie, IN No Include
Muskegon, MI No Include
Myrtle Beach-Conway-North Myrtle
Beach, SC-NC No Include
New Bern, NC No Include

MSA
CJR/SHFFT
Region
AMI/CABG
Eligible
Region
Niles-Benton Harbor, MI No Include
North Port-Sarasota-Bradenton,
FL No Include
Odessa, TX No Include
Olympia-Tumwater, WA No Include
Omaha-Council Bluffs, NE-IA No Include
Owensboro, KY No Include
Palm Bay-Melbourne-Titusville,
FL No Include
Panama City, FL No Include
Parkersburg-Vienna, WV No Include
Peoria, IL No Include
Philadelphia, PA No Include
Phoenix-Mesa-Scottsdale, AZ No Include
Portland-South Portland, ME No Include
Prescott, AZ No Include
Providence-Warwick, RI-MA No Include
Pueblo, CO No Include
Punta Gorda, FL No Include
Raleigh, NC No Include
Rapid City, SD No Include
Redding, CA No Include
Reno, NV No Include
Richmond, VA No Include
Riverside-San Bernardino-
Ontario, CA No Include
Roanoke, VA No Include
Rochester, MN No Include
Rochester, NY No Include
MSA
CJR/SHFFT
Region
AMI/CABG
Eligible Region
Rockford, IL No Include
Rockingham County-Strafford County,
NH No Include
Rocky Mount, NC No Include
Rome, GA No Include
Sacramento--Roseville--Arden-Arcade,
CA No Include
Salem, OR No Include
Salinas, CA No Include
Salisbury, MD-DE No Include
Salt Lake City, UT No Include
San Angelo, TX No Include
San Diego-Carlsbad, CA No Include
San Jose-Sunnyvale-Santa Clara, CA No Include
San Luis Obispo-Paso Robles-Arroyo
Grande, CA No Include
Santa Fe, NM No Include
Santa Maria-Santa Barbara, CA No Include
Santa Rosa, CA No Include
Savannah, GA No Include
Scranton--Wilkes-Barre--Hazleton, PA No Include
Sebring, FL No Include
Sherman-Denison, TX No Include
Shreveport-Bossier City, LA No Include
Silver Spring-Frederick-Rockville, MD No Include
Sioux City, IA-NE-SD No Include
Sioux Falls, SD No Include
Spartanburg, SC No Include

MSA
CJR/SHF
FT
Region
AMI/CABG
Eligible
Region
Spokane-Spokane Valley,
WA No Include
Springfield, IL No Include
Springfield, MO No Include
St. Cloud, MN No Include
St. George, UT No Include
St. Joseph, MO-KS No Include
Stockton-Lodi, CA No Include
Syracuse, NY No Include
Tallahassee, FL No Include
Terre Haute, IN No Include
The Villages, FL No Include
Trenton, NJ No Include
Tucson, AZ No Include
Tulsa, OK No Include
Urban Honolulu, HI No Include
Utica-Rome, NY No Include
Victoria, TX No Include
Visalia-Porterville, CA No Include
Waco, TX No Include
Warner Robins, GA No Include
MSA
CJR/SH
FFT
Region
AMI/CABG
Eligible
Region
Warren-Troy-Farmington
Hills, MI No Include
Washington-Arlington-
Alexandria, DC-VA-MD-WV No Include
Waterloo-Cedar Falls, IA No Include
Wausau, WI No Include
Weirton-Steubenville, WV-OH No Include
Wenatchee, WA No Include
Wheeling, WV-OH No Include
Williamsport, PA No Include
Wilmington, DE-MD-NJ No Include
Wilmington, NC No Include
Winchester, VA-WV No Include
Winston-Salem, NC No Include
Worcester, MA-CT No Include
Yakima, WA No Include
York-Hanover, PA No Include
Youngstown-Warren-
Boardman, OH-PA No Include
Yuba City, CA No Include
Yuma, AZ No Include

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