What are the financial risks in TEAM?  Hospitals are preparing for the launch of the Centers for Medicare and Medicaid Services’ (CMS) Transforming Episode Accountability Model (TEAM) in 2026.   To help you understand both the opportunities and financial risks for participants, DataGen put together a comprehensive white paper, CMS Transforming Episodes Accountability Model Financial Risk Guide.   [Access it Now for Key Updates]  Keep reading for highlights of what’s inside.   Exploring the goals and structure of CMS TEAM Model  CMS TEAM Model is designed to enhance care quality and cost-efficiency. It aims to revolutionize how hospitals manage patient care over 30-day episodes for specific surgical procedures by holding them accountable for the quality and cost of care delivered.   As seen on CMS’ Transforming Episode Accountability Model overview fact sheet , this model not only seeks to improve patient outcomes, but encourages hos...

The end of the CJR model: A look back at its evolution  In October 2024, the final episodes of the Comprehensive Care for Joint Replacement (CJR) model were initiated, with all episodes ending by Dec. 31, 2024. This was the final performance year of CJR, which spanned eight years overall.   CJR began Apr. 1, 2016. It was CMS’ first mandatory bundled payment model. Hospitals were held financially accountable for lower extremity joint replacement (LEJR) episodes of care and were incentivized to improve care coordination for patients across the continuum.    Key insights from CJR: Successes, adjustments and challenges  CJR had numerous ups and downs over the years, as its scope was adjusted over several administrations through the rule-making process. Here are the five main highlights.  1. CJR’s mandatory participation: A changing landscape  When the CJR model was introduced, participation was mandatory for hospitals in 67 metropolitan statistical a...

Health equity remains one of the most pressing challenges in the healthcare industry today. The Centers for Medicare and Medicaid Services (CMS) is taking a significant step forward with the Making Care Primary (MCP) model to address these disparities.  CMS' MCP model aims to improve care quality and ensure that everyone, regardless of their background, has access to essential health services. Using CMS' goals and perspective, we will explore how the MCP model promotes health equity, its crucial components and its implications for healthcare professionals.  Understanding the Making Care Primary Model  CMS is leveraging the MCP model to transform the delivery of primary care services, using insights from previous models like Primary Care First (PCF). It focuses on supporting healthcare providers in delivering advanced care that meets patients' diverse needs, aiming to create a more equitable healthcare system.  The MCP model is about improving patient outcomes and emp...

Healthcare policy is constantly evolving, and with the release of the CMS calendar year 2025 OPPS proposed rule, healthcare providers and administrators have much to consider. This comprehensive guide aims to decode the proposed changes and their potential impact on the healthcare landscape. Whether you're a provider, hospital administrator, medical coder or other healthcare professional, understanding these updates is crucial for staying ahead.  Understanding the CMS CY 2025 OPPS proposed rule  On July 10, the Centers for Medicare & Medicaid Services (CMS) released the proposed CY 2025 payment rule for the Medicare outpatient prospective payment system (OPPS). This yearly update includes modifications that affect Medicare fee-for-service outpatient payment rates and introduces new policies aimed at improving healthcare delivery.  Key changes in the proposed rule  The proposed rule encompasses several notable changes, including the addition of services to the inp...

On July 10, the Centers for Medicare & Medicaid Services (CMS) released its calendar year 2025 Medicare Hospital Outpatient Prospective Payment System and Ambulatory Surgical Center Payment System proposed rule. This proposed rule is more than just a list of updates; it's a roadmap that will shape the future of ambulatory surgery centers (ASCs). Understanding these changes is crucial for ASCs looking to adapt and thrive in an evolving healthcare landscape.  In this blog post, we will explore the key proposals outlined by CMS, including adjustments in payment rate settings, additions to covered procedures and new measures for quality reporting. Our goal is to provide you with a comprehensive overview of the potential impacts on your operations, helping you make informed decisions as you prepare your comments for CMS before the Sept. 9 deadline.   Unpacking the CY 2025 ASC Proposed Rule  At the heart of the CY 2025 proposal is a series of strategic changes aimed at enha...

On July 31, the Centers for Medicare and Medicaid Services (CMS) released the federal fiscal year (FFY) 2025 final payment rule for the Inpatient Psychiatric Facility (IPF) Prospective Payment System (PPS). The significant updates made in this rule have been a long time coming, considering this payment setting has not seen substantial revisions in many years.   Let's break down what these changes mean for healthcare providers and policy analysts: Think of this as your IPF PPS fact sheet!   Understanding the adopted changes  Aligning ECT payments  One of the pivotal changes in the FFY 2025 IPF PPS final payment rule is the alignment of IPF PPS payments that include electroconvulsive therapy (ECT) payments with the increased cost of furnishing ECT. CMS analyzed the most recent outpatient PPS (OPPS) cost data to consider changes to the IPF ECT payment for FFY 2025. Based on this analysis, CMS will use the calendar year (CY) 2024 OPPS pre-scaled, pre-adjusted geometric m...

Key IPPS updates you need to know about  On April 10, Centers for Medicare & Medicaid Services (CMS) released the federal fiscal year (FFY)   2025 Medicare Inpatient Prospective Payment System proposed rule . This rule proposes significant changes and updates to Medicare fee-for-service (FFS) payments and policies.  Understanding these changes is crucial for healthcare professionals, state hospital associations and multi-state health systems. This blog aims to break down the key points and implications of this proposed rule to help you stay informed and prepared.  Overview of the proposed rule  The proposed rule includes regular updates to wage indexes and the market basket. Below are some policies being proposed.  1. Data utilization for standard calculations  CMS plans to use FFY 2023 Medicare Provider Analysis and Review (MedPAR) claims data and FFY 2022 Hospital Cost Reporting Information System (HCRIS) data for standard calculations. Using Med...

On Nov. 2, CMS finalized the calendar year 2024 Medicare Outpatient Prospective Payment System final rule . The 2024 OPPS final rule includes policies that will: add 10 services to the Inpatient Only list; establish an intensive outpatient program; expand the partial hospitalization program rate structure; update payment rates and policies for ambulatory surgical centers; update the requirements for the Hospital Outpatient Quality Reporting Program; outline quality program requirements for Rural Emergency Hospitals; and standardize the reporting of standard chart data using a CMS template. Read on to learn essential OPPS final rule information, important details and dates. We’ll also reveal how you can register for DataGen’s upcoming client exclusive OPPS rule analysis webinar . 4 key CMS 2024 OPPS final rule components 1. Expanded and updated rates CMS estimates a 2.1% rate increase for CY 2024, which represents a $6 billion increase in outpatient payments compared to the CY 2023 OPPS...

Multiple organizations have prioritized provider health equity requirements — from new CMS priorities in their Framework for Health Equity to accreditation standards from The Joint Commission. NCQA’s Health Equity Accreditation is one of its newest programs . Introduced in 2021, HEA expands accreditation from payers to multiple stakeholders including medical practices and health systems. A second NCQA accreditation, Health Equity Accreditation Plus, takes practices further into the social drivers of health and community partnerships. With so many existing demands, it’s natural for a medical practice to ask: Why should we pursue HEA or HEA+, and what are the benefits for our patients and practice? In this blog, we’ll cover three ways NCQA accreditation helps medical practices improve health equity and achieve full practice transformation under this new model of care. How NCQA Health Equity Accreditation can reduce health disparities 1. Increase patient awareness NCQA’s HEA standards hel...

CMS released important updates for Model Year 7 of Bundled Payments for Care Improvement Advanced. Providers who applied and have been accepted into the third cohort will soon begin the baseline evaluation and episode selection process. In this blog, we’ll cover important upcoming BPCIA dates and what you need to know now and for the future. Important upcoming CMS BPCIA dates Here are important BPCIA dates you’ll want on your radar in the coming months: September 2023 : At the beginning of the month, CMS will upload preliminary BPCIA Model Year 7 episode target prices and baseline episode and claims data on the CMS Enterprise Portal. As a provider, you will need to use these data to evaluate which clinical episode service line groups you want to participate in during the new model year. Dec. 4, 2023 : Providers who choose to move forward in the model have until this date to submit their MY7 Participation Agreement and Participant Profile, which will indicate selected episode initiators...

CMS’ new Enhancing Oncology Model seeks to improve cancer care coordination, drive practice transformation and reduce Medicare fee-for-service spending through episode-based payment. Launched July 1, EOM replaces the Oncology Care Model as CMS seeks to build on lessons learned and challenges of cancer care cost management. In this blog, we explore five best practices your oncology practice can use to kick-start EOM. How to operationalize your Enhancing Oncology Model 1. Lay the foundation with core value-based care principles While CMS models change, many value-based care elements are evergreen and can benefit from practices that: identify physician champions; inform and align practice leadership; define success markers to track progress; identify core team member roles and goals; and establish quality measure reporting. The latter may require EOM practices to add metrics to their electronic health records, such as depression screening and pain management. While this example is model-...

The Hospital Inpatient Prospective Payment System proposed rule for federal fiscal year 2024 includes a change to the rural wage index calculation that has the industry buzzing because it would affect all hospitals – rural and non-rural alike. If finalized, CMS will calculate each state’s RWI with data from rural hospitals and reclassified hospitals, even if those facilities are not rural geographically. As HealthLeaders notes , CMS’ approach since FFY 2020 has been to exclude reclassified hospitals from the rural floor calculation if they were not physically rural. Why the change? Who stands to lose or gain? And what other changes should hospitals watch for? What is the rural wage index? With the FFY 2024 rule, CMS proposes to reverse its exclusion of hospitals redesignated as rural from the RWI calculation. DataGen Senior Healthcare Data and Policy Analyst Jacob Orsini notes that hospitals can reclassify if they are either near a rural area or have a patient population with enough...