Hart Health Strategies Summary of Mandatory TEAM APM Proposed Rule

Quality, Coding & Documentation Committee (QCDC)

Hart Health Strategies Summary of Mandatory TEAM APM Proposed Rule

Posted by name on May 9, 2024 at 4:22 pm
Since EDPMA is Hart Health’s client, we remind you that these summaries are for EDPMA leaders only and should not be shared within your organizations or other people.

On April 10th, the Centers for Medicare and Medicaid Services (CMS) issued the fiscal year (FY) 2025 Inpatient Prospective Payment System (IPPS) proposed rule. As part of that rulemaking vehicle, CMS also put forth the proposals for a new, mandatory APM. Attached is our summary of the proposed mandatory APM, the Transforming Episode Accountability Model or TEAM. Our summary includes a Table of Contents and hyperlinks throughout the document and to the original text of the proposed rule, which we hope makes it a little easier to navigate all of the content. Generally speaking, emergency physicians won’t be directly enlisted as “participants” in the model, but we wanted to flag that it is a total cost of care model for 30 day episodes, so reducing unnecessary returns to the hospital is a key goal of the model. In addition, there may be questions from some members as it is revealed to hospitals that they are in geographic areas will participation will be mandatory.

There are additional details in the summary, but the main structure of the APM is as follows:
- Timing: The model is scheduled to starts on January 1, 2026
  and run for 5 performance years (12 month calendar years)
- Mandatory: The model will be mandatory for the hospitals that
  are required to participate in “selected geographic areas.” These will be
  Core-Based Statistical Areas (CBSAs), and we estimate that about 200 will
  be selected (25% of the around 800 CBSAs that have not been excluded). The
  CBSAs will be randomly selected across 17 stratifications based on the
  following characteristics of the CBSAs: The average historical
  episode spending; the number of hospitals; the number of safety net
  hospitals; and the CBSA’s exposure to prior CMS bundled payment models.
- Model Type:
- Episode-based payment model triggered by a hospital stay (inpatient or
  outpatient as appropriate) for one of the following procedures:
- Lower extremity joint replacement
- Surgical hip femur fracture treatment
- Spinal fusion
- Coronary artery bypass graft
- Major bowel procedure
30 day episodes
Target pricing with a
reconciliation against the target to
determine whether the participant hospital receives or owes money. (All
providers will submit claims like normal and payment changes happen
in the context of reconciliation. The target pricing includes all of the
following service (even for persons or entities on the list that are not
“participants”).

Physicians’ services
Inpatient hospital services, including services paid
through IPPS operating and capital payments
Inpatient psychiatric facility (IPF) services
Long-Term Care Hospital (LTCH) services
Inpatient Rehabilitation Facility (IRF) services
Skilled Nursing Facility (SNF) services
Home Health Agency (HHA) services
Hospital outpatient services
Outpatient therapy services
Clinical laboratory services
Durable medical equipment
Part B drugs and biologicals except for those
excluded under §512.525 (f) as proposed
Hospice services
Part B professional claims dated in the 3 days prior
to an anchor hospitalization if a claim for the surgical procedure for
the same episode category is not detected as part of the hospitalization
because the procedure was performed by the TEAM participant on an
outpatient basis but the patient was subsequently admitted as an
inpatient

However, CMS proposes that episodes would exclude costs associated with delivery of services in the following categories:

· Hospital admissions and readmissions for oncology, trauma medical admissions, organ transplant, and ventricular shunts (identified by specific MS–DRGs) and all admissions related to the following excluded Major Diagnostic Categories (MDC): MDC 02 (Diseases and Disorders of the Eye); MDC 14 (Pregnancy, Childbirth, and Puerperium); MDC 15 (Newborns) ; MDC 25 (Human Immunodeficiency Virus)

· IPPS new technology add-on payments for drugs, technologies, and services

· OPPS transitional pass-through payments for medical devices

· Drugs or biologics that are paid outside of the MS–DRG, specifically hemophilia clotting factors

· Certain Part B payments for high-cost drugs and biologicals, low-volume drugs, and blood clotting factors for hemophilia patients

Participants & QPP APM
Status: Unlike BPCI, the episodes can only be
triggered by hospitals in the program where the surgery is done (not
because a Physician Group Practice (PGP) is signed up to participate and
then the surgeon in that PGP does the surgery). Of course, a surgeon will
be doing the surgery, but it’s the fact that it is done at a hospital
that is required to participate that would trigger the episode. Regarding
their decision to not include physician group practices as
“participants”: “We believe there are other meaningful opportunities
for PGPs to engage in TEAM, specifically through financial arrangements
with TEAM participants, or through other CMS value-based care
initiatives, including future PGP-specific opportunities under
development through the CMS Innovation Center specialty care strategy.”
However, CMS generally expects that the model will an Advanced APM for
QPP (if participant attests to meeting CEHRT requirements)- surgeons and
other providers would be able to get Advanced APM credit if they are
“TEAM Collaborators” (i.e. in a financial arrangement with the
“participating hospital” or on the “Clinician Engagement List” that the
hospital provides CMS).

Quality Measurement. The TEAM episodes have quality measures associated
with them that will provide the basis of a Composite Quality Score, which
will feed into the participants reconciliation amount that could increase
or decrease what the hospital owes or is to receive. The measures proposed
for inclusion include:

Hybrid Hospital-Wide All-Cause Readmission Measure
with Claims and Electronic Health Record Data (CMIT ID #356)
CMS Patient Safety and Adverse Events Composite (CMS
PSI 90) (CMIT ID #135)
Hospital-Level Total Hip and/or Total Knee
Arthroplasty (THA/TKA) Patient-Reported Outcome-Based Performance Measure
(PRO-PM) (CMIT ID #1618)

Note that CMS also puts forward several measures for consideration for potential adoption after performance year 1.

Risk:
“glide path” to downside risk- with 3 tracks:

Track 1 would have no downside risk and lower
levels of reward for the first year;
Track 2 would be associated with lower levels
of risk and reward for certain hospitals, such as safety net
hospitals, for years 2 through 5; and
Track 3 would be associated with higher levels
of risk and reward for years 1 through 5

Comments can be submitted on the proposed model via the FY 2025 IPPS rulemaking comment period, which has a deadline of June 10, 2024.