On December 20, 2016, the Centers for Medicare & Medicaid Services (CMS) finalized regulations regarding the Acute Myocardial Infarction (AMI) Model in the Advancing Care Coordination through Episode Payment Models final rule.
This final rule implements a new payment model for Part A and B items and services provided to Medicare fee-for-service beneficiaries undergoing hospitalization for AMI. The Model is being implemented under section 1115A of the Social Security Act. The Model furthers CMS’ goal of improving the efficiency and quality of care for Medicare beneficiaries with AMI, a common and serious condition, and encourages hospitals, physicians, and post-acute care providers to work together to improve the coordination of care from the initial hospitalization through recovery.
Proposed Rule: Cancellation of Advancing Care Coordination through Episode Payment Models (EPMs) and the Cardiac Rehabilitation (CR) Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Payment Model (CJR)
This proposed rule proposes to cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model and to rescind the regulations governing these models. It also proposes to revise certain aspects of the Comprehensive Care for Joint Replacement (CJR) model, including: giving certain hospitals selected for participation in the CJR model a one-time option to choose whether to continue their participation in the model; technical refinements and clarifications for certain payment, reconciliation and quality provisions; and a change to increase the pool of eligible clinicians that qualify as affiliated practitioners under the Advanced Alternative Payment Model (APM) track. Comments on this proposed rule must be received at one of the addresses provided in the proposed rule no later than 11:59 p.m. EST on October 15, 2017. The proposed rule is now available.
Acute care hospitals in certain selected geographic areas will participate in retrospective bundled payments for items and services that are related to AMI treatment and recovery, beginning with a hospitalization for AMI treatment and extending for 90 days following hospital discharge. Under the AMI Model, the hospital is financially accountable for the quality and cost of an AMI episode of care, which incentivizes increased coordination of care among hospitals, physicians, and post-acute care providers. An AMI episode is defined by the admission of an eligible Medicare fee-for-service beneficiary to a hospital paid under the Inpatient Prospective Payment System (IPPS) that eventually results in a discharge paid under the following Medicare Severity-Disease Related Group (MS-DRG):
- MS-DRG 280 (Acute myocardial infarction, discharged alive with MCC),
- MS-DRG 281 (Acute myocardial infarction, discharged alive with CC),
- MS-DRG 282 (Acute myocardial infarction, discharged alive without CC/MCC).
In addition to AMI MS-DRGs, an MS-DRG for percutaneous catheter insertion (PCI) which includes an AMI ICD-10-CM diagnosis code in the principal or secondary position on the IPPS claim will initiate an AMI model episode. The following PCI MS-DRGs are eligible to initiate an AMI episode, as long as the criteria for AMI diagnosis code as specified previously is met:
- MS-DRG 246 (Percutaneous cardiovascular procedures with drug-eluting stent with MCC or 4+ vessels/stents),
- MS-DRG 247 (Percutaneous cardiovascular procedures with drug-eluting stent without MCC),
- MS-DRG 248 (Percutaneous cardiovascular procedures with non-drug-eluting stent with MCC or 4+ vessels/stents),
- MS-DRG 249 (Percutaneous cardiovascular procedures with non-drug-eluting stent without MCC),
- MS-DRG 250 Percutaneous cardiovascular procedures without coronary artery stent with MCC), and
- MS-DRG 251 (Percutaneous cardiovascular procedures without coronary artery stent without MCC).
The first performance period will begin on July 1, 2017 and will continue for five performance years, ending on or about December 31, 2021.
The AMI Model will be implemented in 98 geographic areas, defined by MSAs. MSAs are counties associated with a core urban area that has a population of at least 50,000. Non-MSA counties (no urban core area or urban core area of less than 50,000 population) were not eligible for selection. Eligible MSAs must have had at least 75 AMI model eligible cases which were not attributed to the Bundled Payments Care Improvement (BPCI) initiative between January 2014 and December 2014, and the percentage of BPCI eligible AMI episodes must have been less than 50 percent because BPCI episodes are excluded from the model. From a random sampling of 293 eligible MSAs, 98 MSAs were selected and are listed below:
CMS estimates approximately 1,120 hospitals will participate in the AMI model.
The episode of care continues for 90 days following discharge and almost all Part A and Part B services provided in those 90 days are included in the episode price. For each performance year of this model, CMS will set Medicare episode prices for each participant hospital that include payment for all related services furnished to eligible Medicare fee-for-service beneficiaries who are treated and discharged for AMI eligible DRGs at that hospital. Prices will also be set based on census region and the target prices used will be a blend of provider specific and regional pricing.
Quality and the Pay-for-Performance Methodology
The AMI Model has the potential to improve quality in four ways. First, the Model adopts a quality-first principle where hospitals must achieve a minimum level of episode quality before receiving reconciliation payments when episode spending is below the target price. Second, higher episode quality, considering both performance and improvement, may lead a hospital to receive quality incentive payments based on the hospital’s composite quality score, a summary score reflecting hospital performance and improvement on the following three measures:
- Hospital 30-day, All-cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Myocardial Infarction (NQF #0230); and
- Excess Days in Acute Care after Hospitalization for AMI; and
- Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey (NQF #0166)
The composite quality score also takes into consideration a hospital’s submission of Voluntary Hybrid Hospital 30-day, All-Cause, Risk-Standardized Mortality Rate Following Acute Myocardial Infarction Hospitalization (NQF #2473) data submission.
Third, in addition to quality performance requirements, the Model incentivizes hospitals to avoid expensive and harmful events, which increase episode spending and reduce the opportunity for reconciliation payments.
Fourth, CMS provides additional tools to improve the effectiveness of care coordination by participant hospitals in selected MSAs. These tools include: 1) providing hospitals with relevant spending and utilization data; 2) waiving certain Medicare requirements to encourage flexibility in the delivery of care; and 3) facilitating the sharing of best practices between participant hospitals through a learning and diffusion program.
Beneficiary Benefits and Protections
Beneficiaries retain their freedom of choice to choose services and providers. Physicians and hospitals are expected to continue to meet current standards required by the Medicare program. All existing safeguards to protect beneficiaries and patients remain in place. If a beneficiary believes that his or her care is adversely affected, he or she should call 1-800- MEDICARE or contact their his or her state’s Quality Improvement Organization by going to http://www.qioprogram.org/contact-zones. The establishment of an Alternative Payment Models Beneficiary Ombudsman will also ensure monitoring of the models and fielding inquiries from beneficiaries if needed. The final rule also describes additional monitoring of claims data from participant hospitals to ensure that hospitals continue to provide all necessary services.
- AMI Provider and Technical Fact Sheet (PDF)
- Final Rule
- Final Rule Press Release
- Proposed Rule
- Proposed Rule Fact Sheet
- Proposed Rule Press Release
- AMI-CABG Provider List (ZIP)
- AMI Model Parameters (ZIP) – contains episode initiating MS-DRGs, excluded readmission MS-DRGs, and other exclusions from model