Background
People with Original Medicare undergoing a surgical procedure either in the hospital or as an outpatient may experience fragmented care that can lead to complications in recovery, avoidable hospitalization, and other high costs. This is because, in a fee-for-service (FFS) payment system, providers and suppliers are paid separately for each service and procedure, potentially resulting in fragmented care, duplicated use of resources, and avoidable utilization.
Model Aims
TEAM aims to improve health outcomes for people with Original Medicare who receive one of the included surgical procedures by:
- improving care transitions,
- encouraging provider investment in health care infrastructure and redesigned care processes, and
- incentivizing higher value care across the inpatient and post-acute care settings for the episode.
Innovation
Holding participants accountable for all the costs of care for an episode incentivizes care coordination, can improve patient care transitions, and decreases the risk of avoidable readmission. As part of taking responsibility for cost and quality during the episode, participants will connect patients to primary care services to help establish accountable care relationships and support optimal, long-term health outcomes.
Design
TEAM will test an episode-based payment approach in which acute care hospitals participating in the model will receive a target price to cover all costs associated with the episode of care, including the cost of the hospital inpatient stay or outpatient procedure and items and services following hospital discharge, such as skilled nursing facility stays or provider follow-up visits.
Episodes will begin with a person’s hospital inpatient stay or hospital outpatient procedure for one of the following surgical procedures: lower extremity joint replacement, surgical hip femur fracture treatment, spinal fusion, coronary artery bypass graft, and major bowel procedure. Each episode will end 30 days after the individual leaves the hospital.
TEAM participants will continue to bill Medicare FFS as usual but will receive target prices for included episodes prior to each performance year. Target prices will be based on all Medicare Parts A & B items and services included in an episode and will be risk-adjusted based on beneficiary-level and hospital-level factors.
Performance in the model will be assessed by comparing the participants’ actual Medicare FFS spending for the episode to their target price, as well as through an assessment of performance on specific quality measures. TEAM participants may earn a payment from CMS, subject to a quality performance adjustment, if the total Medicare costs for the episode are below the target price. TEAM participants may owe CMS a repayment amount, subject to a quality performance adjustment, if the total Medicare costs for the episode are above the target price.
The model is designed to complement longitudinal care management through policies that align with Accountable Care Organizations (ACOs) and promote primary care referrals. Under TEAM, a person receiving care from (aligned to) providers in an ACO will be in an episode if they receive one of the surgeries included in TEAM at a hospital that is participating in TEAM. Allowing a person with Original Medicare to be included in both TEAM and ACO initiatives will encourage provider collaboration. Also, TEAM will require hospitals to refer patients to primary care services to support continuity of care, preventive care, and positive long-term health outcomes.
