With the goal of developing a new episode-based model to be implemented no earlier than 2026, the Center for Medicare and Medicaid Innovation (CMMI) is requesting input on model design and incentives, as well how to achieve increased specialist engagement within broader Accountable Care Organizations (ACO). The Agency is specifically interested in securing feedback on the following seven key areas by August 17, 2023:

A. Care Delivery and Incentive Structure Alignment

To date, CMMI episode-based payment models have focused on acute inpatient and hospital outpatient episodes of care. The Agency is seeking to establish episodes of care that would achieve better alignment across providers through models that strengthen communication, collaboration and coordination.

B. Clinical Episodes

Currently, CMMI considers clinical homogeneity, spending variability, episode volume, quality impact, and episode overlap alignment when determining appropriate clinical indications for episode-based payment. The Agency is seeking feedback on whether shorter episodes of care, such as 30-day episodes, would allow for more coordinated care between principal providers and primary care providers.

C. Participants

CMMI designates participants as those providers who assume accountability for cost and quality performance. Participant eligibility has varied among defined episode of care models. In this RFI, CMMI is seeking input on different types of potential participants, such as hospitals and Physician Group Practices (PGPs), and whether it should consider attribution of episodes to a single accountable entity or weight attribution for multiple accountable entities.

D. Health Equity

Improving access to high-quality, patient-centered care, and ensuring underserved beneficiaries are adequately represented in value-based care models may help reduce inequities. According to the RFI, future payment models may also need to consider the use of area level indicators, such as the social deprivation index (SDI), the social vulnerability index (SVI), and the area deprivation index (ADI) to help address increased social needs of beneficiaries, while also determining if additional risk adjustments benefit underserved groups. To achieve these goals, the Agency is seeking feedback on whether risk adjustments should be made to financial benchmarks to account for higher costs of traditionally underserved populations and safety net hospitals.

E. Quality Measures and Multi-payer Alignment

Per statute, Innovation Center models are expected to improve or maintain quality of care while reducing or maintaining program expenditures. Currently, models use a combination of claims data, participant-reported or registry-based quality measures, and patient-reported outcomes (PRO) measures to incentivize improvement and assess model performance. CMS is seeking input on how to improve alignment across models and programs to simplify relative comparison of quality performance, and to effectively track quality, outcomes, patient experience, and interoperable exchange of care data that is required to generate evidence that models improve quality of care.

F. Payment Methodology and Structure

Current model payment methodologies involve the development of preliminary target prices prior to the performance period, wherein participants are paid through the traditional FFS payment system during the performance period and are then subject to reconciliation against the target price. CMS seeks input on ways to address some of the challenges associated with the current payment methodology construct including the reconciliation timeline, target price methodology and risk adjustment calculation. The Agency is also interested in alternative methodologies that warrant consideration.

G. Model Overlap

Existing payment models have been designed to avoid overlap due to concerns about duplicative incentive payments and giving precedence to a single accountable entity. CMS recognizes that this policy does not promote meaningful collaboration and may have resulted in confusing methodologies and misaligned incentives. In this RFI, the Agency seeks input on how it could allow overlap without double paying incentives, while at the same time incentivizing efficiency and provider collaboration.