CMS’s Mandatory AMI Bundle Is Cause for Chest Pain

This week the Centers for Medicare & Medicaid Services (CMS) announced a new mandatory bundled payment program for cardiac care. The proposed 5-year demonstration would go into effect on July 1, 2017, in 98 to-be-identified markets. The model would make hospitals financially accountable for the cost and quality of care for acute myocardial infarction (AMI) and coronary artery bypass graft (CABG) during inpatient stays and for 90 days following discharge. Continue reading

The Shift From Grouper to APC Reimbursement: Advice for ASCs and HOPDs

In 2008, when the Centers for Medicare & Medicaid Services (CMS) shifted its payment approach in the outpatient surgery industry from the nine-grouper methodology to APC-based reimbursement, many assumed that commercial payors would follow suit. But the majority of insurers continued to base reimbursement to ambulatory surgery centers (ASCs) and hospital outpatient departments (HOPDs) on grouper-based methodologies. Their models remained enhanced or modified versions of the historical CMS ASC model, with a few differences such as mapping of CPT codes and additional groupers. The resistance to adopting an APC-based model was largely due to the high system and operational costs associated with making the switch. Continue reading

MACRA Forces Providers Seeking APM Track to Move Quickly

In the recent proposed rules for MACRA, CMS offered some clarity for providers who are trying to decide whether to participate under the Merit-Based Incentive Payment System (MIPS) or the Alternative Payment Model (APM) track.  In short, it really is not a decision that the provider makes, but rather a determination made by CMS based on the provider’s level of participation – if any – in qualifying APMs (also known as advanced APMs). Continue reading

MACRA Proposed Rules Provide Some Clarity, But Questions Remain

Last week CMS released its much-anticipated proposed rules for the Medicare Access and CHIP Reauthorization Act (MACRA), which was passed by Congress approximately 1 year ago and introduced substantive changes in the way Medicare will reimburse physician services. Readers of previous ECG blog posts and articles may recall that, like the ACA before it, this legislation grants the HHS Secretary great latitude in fleshing out the details through rulemaking. While these are only proposed rules, and CMS is using this as an opportunity to solicit commentary from the public, they do shed light on what we can expect when the rules are finalized in November. Continue reading

MACRA Draft Plan Is Short on Details

On December 18, 2015, CMS released its draft plan for developing the quality measures that will be used within both the MIPS and APM components of MACRA. The purpose of this draft plan and the mandate for the Secretary of HHS, at least theoretically, is to:

  • Address how measures used by private payors and integrated delivery systems could be incorporated into Title XVIII (i.e., Medicare).
  • Describe how coordination across organizations developing such measures might occur.
  • Take into account how clinical best practices and clinical practice guidelines should be used in the development of quality measures.

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