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CMS finalizes additional delay for episodic payment programs

John Howard June 9, 2017

After earlier delays following the change in administration and leadership, the Centers for Medicare and Medicaid Services (CMS) has set the start date for cardiac episode payment models (EPMs) and revisions to the Comprehensive Care for Joint Replacement (CJR) to Jan. 1, 2018.

The rule establishing mandatory cardiac EPMs and revising the requirements and scope of the mandatory CJR model has been pushed back to the beginning of 2018. Hospitals in certain metropolitan statistical areas will be paid based on CMS target pricing for both inpatient and post-discharge care, running from the date of admission to 90 days following discharge for the following episodes of care:

  1. Acute myocardial infarction (AMI)
  2. Coronary artery bypass graft (CABG)
  3. Surgical hip/femur treatment (SHFFT)

The SHFFT are to be additional episodes under the CJR model, which included initially, beginning April 1, 2016, lower extremity joint replacement surgeries (DRG 469 and DRG 470). The cardiac bundle rule also contains provisions to promote the use of cardiac rehabilitation services during the 90 days following discharge for beneficiaries with an AMI or CABG episode.

These EPMs are aimed at improving the efficiency and quality of care for Medicare beneficiaries by encouraging providers to work together to improve the coordination of care from the initial hospitalization through recovery.

CMS noted that the delay in implementing the cardiac EPMs allows hospitals sufficient time to prepare for the mandatory program and for the agency to address whether additional modifications are warranted. A number of comments again suggested that the program be converted to a voluntary episode payment model, but CMS did not respond to the comments at this time because the latest rulemaking was only about the delayed effective date.

This information is also available on CMS’s EPM website.

John Howard is a partner in the firm's health care practice. Summer associate Lauren Pair also contributed to this article.