“… GAO was asked to review the episode-based payment models developed by CMS. This report (1) describes the characteristics of the providers that participated in these models and (2) compares the relative advantages of voluntary versus mandatory episode-based payment models, as identified by stakeholders.”
“GAO analyzed CMS data on participants and other providers and reviewed CMS’s evaluations of the models. GAO also interviewed multiple stakeholders, including officials from CMS, its contractors, selected providers and organizations representing providers, as well as Medicare experts…”
“As of February 2018, the Centers for Medicare & Medicaid Services (CMS) had tested, or was in the process of testing, six episode-based payment models as alternatives to traditional Medicare. In these models, rather than pay providers largely based on the volume and complexity of each individual service, CMS establishes a target payment amount to cover the costs of all the services Medicare beneficiaries may receive during a defined “episode of care” initiated by a health care event, such as a surgical hospitalization. Providers can earn additional payments if they treat beneficiaries for less than the target amount and meet certain quality metrics; in some models, providers may be penalized for expenditures that exceed the target amount or if the care provided does not meet quality goals. Provider participation in all but one of the six models being tested is entirely voluntary (i.e., eligible providers may choose to participate in the model and generally have an option to leave the model before testing ends), with participation in the remaining model mandatory for some providers (i.e., eligible providers must participate and cannot leave the model before testing ends).”
“According to CMS data and reports that GAO reviewed, providers participating in the six episode-based payment models typically had more beds or larger practices, had higher episode volume, and were more often located in urban areas compared to all providers that participated in traditional Medicare. Stakeholders—participants, experts, and provider groups—that GAO interviewed noted that the likelihood for financial gain under voluntary models can influence providers’ decisions to participate in the models…”
Source: Medicare: Voluntary and Mandatory Episode-Based Payment Models and Their Participants – January 22, 2019. GAO.
