Each episode-based payment model has its own specific set of risk arrangements for providers to consider. Risk adjustment or risk stratification is present in these alternative payment models to amend payment levels and reflect cost considerations outside a provider’s control.
In this paper, Milliman’s Samuel Bennett and Tom Snook provide a high-level guide on risk adjustment within the broader scope of four episode-based payment models administered by the Centers for Medicare and Medicaid Services.
The Centers for Medicare and Medicaid Services released final rules related to episode payment models on January 3, 2017, and May 19, 2017. This paper by Milliman consultants Pamela Pelizzari and Daniel Muldoon outlines the major provisions of the final rules and suggests possible implications for affected providers.
The Centers for Medicare and Medicaid Services (CMS) released a notice of proposed rulemaking on July 25, 2016, that includes three major areas of focus:
• The creation of three new Medicare Parts A and B episode payment models (EPMs) under section 1115A of the Social Security Act
• The creation of a new cardiac rehabilitation incentive payment model
• Modifications to the existing Comprehensive Care for Joint Replacement (CJR) model
In addition to these major areas of focus, CMS also addresses the potential future of Medicare bundled payment models, indicating its intention to continue a voluntary bundled payment model after the conclusion of the Bundled Payments for Care Improvement (BPCI) initiative, designed to help providers meet the criteria to take advantage of an Advanced Alternative Payment Model (APM), and inviting input on potential future condition-specific episode payment models.
In this article, Milliman’s Pamela Pelizzari outlines the major provisions of the proposed rule and offers perspective on some possible implications for affected providers.