The Centers for Medicare & Medicaid Services (CMS) published a Request for Information (RFI) on July 18 regarding the design of a future, episode-based payment model on behalf of CMS’s Center for Medicare and Medicaid Innovation (the Innovation Center). Comments in response to the RFI should be submitted by Aug. 17 either online or by mail.

The Innovation Center seeks information from the public to supplement its previous experience with other episode-based payment models, like the Bundled Payment for Care Improvement (BPCI), BPCI Advanced and the Comprehensive Care for Joint Replacement (CJR) models. An episode-based payment model is an alternative payment model (APM) that generally seeks to lower the cost to Medicare from a beneficiary’s overall episode of care as a result of a specific anchoring clinical event.

The new episode-based payment model will be designed to support the Innovation Center’s five strategic objectives, which are drive accountable care; advance health equity; support innovation; address affordability; and partner to achieve health system transformation. To that end, the Innovation Center asked for comments in response to the following specific questions:

• How can CMS structure episodes of care to increase specialty- and primary-care integration and improve patient experience and clinical outcomes?
• How can CMS support providers who may be required to participate in this episode-based payment model?
• How can CMS ensure patient choice and rights will not be compromised as they transition between health care settings and providers?
• How can CMS promote person-centered care in episodes, which includes mental health, behavioral health and non-medical determinants of health?
• How can CMS support multi-payer alignment for providers and suppliers in episode-based and population-based models?
• For population-based entities currently engaging specialists in episodic care management, what are the key factors driving improvements in cost, quality and outcomes?
• How does the nature of the relationship (that is, employment, affiliation, etc.) between a population-based entity and a specialist influence integration?
• What should CMS consider in the design of this model to effectively incorporate health information technology (health IT) standards and functionality, including interoperability, to support the aims of the model?
• How can CMS include home and community-based interventions during episode care transitions that provide connections to primary care or behavioral health and support patient independence in home and community settings?

Comment

While many involved in BPCI, BPCI Advanced and CJR have had informal interactions with the Innovation Center over the years, this RFI provides an opportunity to articulate specific concerns in writing. Health care providers, health systems and organizations with industry experience with a total cost of care approach to episodic care may be in a unique position to offer significant comments.

Health care providers and stakeholders may also wish to comment on some of the RFI’s concepts that will distinguish the new payment model from the previous models. For example, the RFI suggested strongly that the new model will compel provider participation in specific geographic regions. Required participation was a controversial element of CJR, which led to a reduction in that model’s scope shortly after it started. Aligning care coordination with population health metrics and including mental health elements in the new model reflect the expanding acceptance of health equity and behavioral health services in the new model. Lastly, providers and third-party payers should consider commenting on episode selection and other criteria that should be included in, or excluded from, the new model.

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