Commencing January 1, the Centers for Medicare & Medicaid Services (CMS) will implement a novel alternative payment system for selected hospitals, known as the Transforming Episode Accountability Model (TEAM). This contemporary model will place the onus on participating hospitals to uphold care quality, control costs, and coordinate post-discharge care associated with five specific surgical procedures.
TEAM is an ambitious attempt to cultivate shared accountability and put to test the notion of healthcare providers as collaborative ‘team players’ in the realm of value-based care. It is an exploratory initiative to gauge whether episode-based payments can enhance care quality while curtailing Medicare expenditure. Participating hospitals will hold accountability for the quality and cost of patient care 30 days post-discharge for these five procedures.
Of the more than 700 hospitals engaging in TEAM, a mere fraction of 10 chose to do so voluntarily. CMS certified acute care hospitals, located within a selected Core-Based Statistical Area that accept payment for care episodes under the Inpatient Prospective Payment System (IPPS) and Outpatient Prospective Payment System (OPPS), are mandated to participate in TEAM.
Data collection from a broad spectrum of healthcare organizations is critical, and compulsory participation curtails issues of attrition and selection bias linked with voluntary models. However, hospitals situated in Maryland and those affiliated with the Indian Health Service or Tribal entities are exempt from participation. Ambulatory Surgical Centers (ASCs) and joint-venture ASCs are likewise excused, but the services they provide can be incorporated into the total care episode costs.
CMS plans to execute TEAM in five performance years, with each year starting on January 1 and culminating on December 31, till the year 2030. Each care episode commences with the above-mentioned procedures and extends for 30 days post-discharge. All Medicare services such as those categorized under Part A and Part B, inclusive of post-acute care services, will count toward a single care episode.
CMS will conduct a reconciliation process annually to compare the hospital’s actual per-episode care expenditure to a set target price, roughly six months following the performance year’s end. Hospitals will receive notice of their target prices which are subject to change before each performance year starts and which will fluctuate based on geographic location, initial costs, and patient mix.
The hospital will either earn a reconciliation payment or owe CMS a repayment depending on whether its spending falls below or above the target price. CMS labels this incentive system as encompassing both “upside” and “downside” risk. Quality performance will also impact reconciliation payments. Existing CMS quality measures can lead to an increase or decrease in a hospital’s potential reconciliation payment by 10% to 20%.
CMS has devised three TEAM “tracks” to aid participants in the transition towards the new payment model. Their ultimate goal is to reward stakeholders that succeed in reducing expenditure without compromising on care quality. This achievement is facilitated by incentivizing the careful coordination of care across surgical, inpatient, and post-acute care settings. Furthermore, TEAM is designed to promote prevention and enhance long-term health outcomes by ensuring that patients are promptly referred to primary care services.
Hospital representatives provide insight into strategies and practices that aid in the preparation for the implementation of the TEAM model. These involve building strong alliances. Attention is also given to foreseeing potential obstacles in care transitions and the application of evidence-based practices for optimal clinical outcomes and cost-efficiency. A primary focus is put on enhancing surgical site infection prevention programmes and establishing standard care pathways and postoperative care milestones. Ascertainment of care consistency across providers and sites is also a focused area to reduce complications and increase patient satisfaction.