What to Expect from CMS’ response to COVID-19

Since the U.S. went into various forms of lockdown due to COVID-19 in late March, participants in value-based programs have been wondering if and when the Centers for Medicare and Medicaid Services (CMS) would announce changes to those programs. As the pandemic enters its fourth month in the U.S., the Center for Medicare and Medicaid Innovation (the Innovation Center) has announced several changes that, on the whole, increase flexibility for program participants.

DataGen has assessed the information shared by the Innovation Center-here are our top takeaways by program:

Bundled Payments for Care Improvement Advanced (BPCI-A)

The Innovation Center has announced three options for participants:

• Participants can sign a bilateral amendment and elect to forgo both upside and downside risk by excluding clinical episodes from reconciliation for Model Year 3, comprised of performance periods 3 and 4; participants will not be assessed for quality in performance periods 3 and 4 with this option.

• Participants can sign a bilateral amendment and opt to remain at two sided risk but have episodes where there is a COVID-19 diagnosis removed from reconciliation for Model Year 3, comprised of performance periods 3 and 4; participants will still be assessed for quality in performance periods 3 and 4 with this option.

• Participants can choose not to sign either amendment and remain at two-sided risk for all clinical episodes in Model Year 3, comprised of performance periods 3 and 4. 

All of the options above would be enacted at the participant level. BPCI-A participants will be able to identify beneficiaries impacted by COVID-19 in their monthly data feeds, though details on how this will be done will not be released until CMS publishes the final amendments, which they aim to do within the next few weeks. Participants will have ample time to make a decision on which, if any, amendments they sign. 

Additionally, only current participants and episode initiators can add or remove episode categories for BPCI-A Model Year 4; no new participants or episode initiators can join the program. 

Oncology Care Model (OCM)

The Innovation Center is offering OCM participants two options to select from for episodes impacted by COVID-19:

• Practices can forego both upside and downside risk during the effected performance periods. They will not be responsible for paying CMS recoupment and they will also not be eligible to receive a performance based payment.

• Practices can retain their current risk status (i.e. one-sided or two-sided risk) and remove COVID-19 episodes from reconciliation for effected performance periods.

Both of these options will impact performance periods 7 and 8, and potentially performance period 9. For each option above, participants will still be eligible to bill MEOS payments and will still be responsible for recoupment. 

Quality data reporting will be optional for the impacted performance periods. Participants who choose to opt out of reporting, which can be done as early as performance period 6, must notify CMS by the deadline for data submission. The following are now optional for reporting:

• Clinical and staging data reporting at the beneficiary level: For participants who do not submit clinical and staging data, they will not have the metastatic adjustment applied to their practice for that period (starting in PP7 since that is when the adjustment begins).

• Aggregate quality measure reporting: For those practices that choose to not submit, their AQS score will be based off the remaining claims based measures.

• Cost and resource utilization reporting and practice transformation plan reporting in July/August 2020. 

In addition, OCM has been extended by a year, now running through June, 2022. This includes two new, optional performance periods: 10 and 11. Participants who choose to be a part of the model for those new performance periods must sign new participant agreements and amendments.

CMS plans to distribute the final amendments to participants in the coming weeks, when they will also notify participants of the deadline for making their decision. Participants who have terminated their participation in the program will still be eligible for forgoing upside and downside risk for the effected performance periods if applicable. 

While BPCI-A and OCM had the greatest number of changes related to the COVID-19 response, the Innovation Center announced a few other changes as well:

• Oncology Care First: There was no information provided about this model, but it is likely that, with OCM being extended for a year, this program’s timeline will likely be pushed back.

• Kidney Care Choices (CKCC and KCF): The first performance period for these programs has been delayed from January 1, 2021, to April 1, 2021. There will be a second application cycle during 2021 for a second cohort, scheduled to begin on January 1, 2022.

• Primary Care First: This program is still on track to begin on January 1, 2021; however, the serious illness component’s start is delayed until April 1, 2021.

• Next Gen and MSSP Track 1+ ACOs: Both of these programs have been extended for one year. Downside risk will be reduced proportionate to the duration of the public health emergency.

All in all, these program flexibilities offered by CMS are positive and reflect many of the suggestions recommended to CMS by policy experts. Participants are still facing countless unknowns as a result of the pandemic, and their decision to remain in their respective programs and whether to sign on of the amendments is highly specific to individual participant. We expect decisions to vary on a case by case basis.

John Kalamaras is a manager of business intelligence analytics at DataGen.