Additional opportunities for Advanced Alternative Payment Models (APMs) are now available, as CMS has finalized a number of policies on bundled payments and a new accountable care organization model.

The bundled payments included in the announcement are four new models for cardiac and orthopedic services:

• The Acute Myocardial Infarction (AMI) Model.
• The Coronary Artery Bypass Graft (CABG) Model.
• The Surgical Hip and Femur Fracture Treatment (SHFFT) Model.
• The Cardiac Rehabilitation (CR) Incentive Payment Model.

The four mandatory bundled payments will have hospitals accountable for the quality and cost of care provided to Medicare beneficiaries during their stay and for 90 days after being discharged. The model will run for five years beginning on Jan. 1, 2017.

“All hospital participants that achieve actual spending below the quality-adjusted target price and achieve an acceptable or better (composite quality score) will be eligible to earn up to 5 percent of their target price in performance years 1, 2 and 3: 10 percent in performance year 4; and 20 percent in performance year 5 for the AMI, CABG, and SHFFT Models. Hospitals with model episode spending that exceeds the target price will be financially responsible for the difference to Medicare up to a specified repayment limit,” the CMS fact sheet said.

The addition of new mandatory bundled payment models drew criticism from the American Hospital Association, which argued participation shouldn’t be forced.

“The bundled payment model for cardiac care is the second mandatory demonstration project the agency has finalized in just the past 15 months. This is too much, too soon,” the AHA said in a statement.

The new ACO model being announced is the promised Track 1+ within the Medicare Shared Savings Program. CMS had said in the final Medicare Access and CHIP Reauthorization Act (MACRA) rule it wanted to test a new model which had more limited downside risk than Tracks 2 and 3 “in order to encourage more rapid progression to performance-based risk.”

“The new Model is based on Shared Savings Program Track 1 with maximum 50% shared savings rate, but incorporates elements of Track 3 including: prospective beneficiary assignment to allow ACOs to know in advance the patient population for which they are responsible; choice of symmetrical thresholds from which to start sharing in savings or losses; and the option to elect the (skilled nursing facility) 3-Day Rule Waiver to provide greater flexibility to Track 1+ ACOs to better coordinate and deliver high quality care,” the fact sheet said. “The model has a fixed 30% loss sharing rate and the maximum level of downside risk would vary based on the composition of ACOs with potentially lower levels of risk available to qualifying ACOs that include physicians or small rural hospitals.”

The model will begin in 2018, with practices advised to plan on applying in May 2017. The track will be open to Track 1 ACOs which are within their current agreement period or up for renewal, as well as those new to MSSP entirely.

Along with these announcements, CMS also updated the Comprehensive Care for Joint Replacement (CJR) model, allowing it to qualify as an Advanced APM.