5 Year Model; 6-Month Performance Periods (“PPs”)
Begins 7/2023; Applications Due 9/30/22
Total cost of care (TCC) model, available to practices and payors.
7 Cancers: Breast, Chronic Leukemia, Small Intestine/ Colorectal, Lung, Lymphoma, Multiple Myeloma, Prostate.
MEOS payment of $70 ($100 total for “dual eligibles.” The additional $30 will not count towards the TCC, the $70 will) – with a requirement to furnish enhanced services.
Mandatory downside risk. Semi-annual reconciliation (by PP). One “true-up” per PP.
Baseline Period established via episodes initiated 7/1/16 – 6/30/20 (COVID excluded).
Benchmark includes EOM and Non-EOM performance: National, regional, and practice-level performance all factor in.
Adjustments include clinical, novel therapy, risk, and experience.
Participants may form pooling relationships; risk-sharing permitted with “Care Partners.”
Episodes with CAR T-Cell Therapy removed.
Application responses must address plans to achieve performance redesign activities (PRAs), expected financial results and repayment means in the event of recoupment.
Quality Measure Categories: Participant-reported, claims-based, and patient experience surveys.
Focus: Patient experience, avoidable acute care utilization, management of symptoms toxicity, management of psychosocial health, and management of end-of-life care
Quality measure scores cannot increase performance-based payments but can reduce them. Good scores can reduce recoupment amounts.
Three benefit enhancements: Telehealth, post-discharge home visits and care management home visits.
Claims data available on monthly (or quarterly) basis.
Health equity, collecting and reporting SDOH are key features.