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On behalf of the 61 hospital and health system members of the
Under the Maryland Total Cost of Care Model (
I. Newly proposed value-based exceptions.
A. Full financial risk exception proposed at 42 CFR Sec. 411.357(aa)(1) and meaningful downside financial risk to the physician exception proposed at Sec. 411.357(aa)(2).
Maryland hospitals are subject to fixed-revenue global budgets in addition to all-payer rate setting by the state's
We also echo the suggestions within the
B. Value-based arrangements proposed at 42 CFR Sec. 411.357(aa)(3).
Our previous comment letters on
To this end, we echo AHA's suggestion to expand the proposed definition of value-based purpose to protect appropriate cost reductions for provider participants, and not just for purposes that result in cost-savings for payers. This expansion ensures that care redesign programs supporting the Maryland Model, such as the Hospital Care Improvement Program, can continue to flourish and create internal cost-savings for Maryland's hospitals. This ultimately results in lower costs to payers.
Furthermore, as we move ahead with the Maryland Model, both hospital and non-hospital providers have recognized that expansion of value-based arrangements is key to achieving its goals. Therefore, we applaud CMS's proposal for a value-based arrangement exception. It permits value-based enterprise (VBE) participants that are part of the arrangement to set their own benchmarking, remuneration, and quality methodologies, regardless of the level of risk involved. This flexibility is the key to modernization.
Thus, we hope CMS finalizes the provision as-is, rather than adopting the proposed alternatives. Moreover, we echo the AHA's suggestion that any compliance monitoring obligations should be included explicitly within the regulations, with clear guidance from CMS on the specific monitoring that will be required of hospitals.
II. Decoupling required compliance with Anti-Kickback Statute (AKS) and other federal or state laws governing billing or claims submission from the Stark Law exceptions.
CMS's decoupling of the requirement that an arrangement which fits within a
III. Request for comments regarding price transparency.
Along with AHA, we urge CMS not to move forward with a requirement related to price transparency in every exception for the newly proposed value-based arrangements. We are concerned that this provision overlaps with the recently finalized price transparency requirements that were issued in November, thus potentially inundating patients with duplicative and ineffective notices. It also runs counter to CMS's efforts to reduce unnecessary paperwork that benefits neither patients nor providers.
Given the continually evolving policy conversations around this issue, we welcome robust and focused stakeholder engagement processes led by CMS specifically on price transparency rather than through the lens of the proposed
IV. Removing the monetary cap on aggregate retail value of patient engagement tools and supports for newly proposed safe harbor.
We appreciate OIG's recognition that health care is not limited to the provision of medical items and services. Social determinants of health, such as transportation burdens and housing issues ranging from access to safety, also must be addressed. As we focus not only on the care needs of patients we serve but also on improving the health of all people in our communities, Maryland's hospitals expend effort and resources to meet social and other non-medical needs. Doing so entails an investment that is significantly more than
For example, our member hospitals have expressed interest in providing financial assistance for housing modifications to lessen chances of falls or other injuries that lead to hospitalization. Such modifications (e.g., installation of handrails) may easily run higher than the proposed limit, but the benefits from these investments--preventing future hospitalizations and allowing individuals to remain safely in their homes--far outweigh the expense. Although OIG indicates that some supports furnished may exceed the limit based on the patient's financial need, the appropriateness of these instances would be determined on a case-by-case basis.
We seek additional details regarding the criteria upon which each case will be judged. Success of the Maryland Model will require scalable innovations around social needs and determinants; we are therefore concerned this low threshold will hinder providers' ability to address non-medical needs in a manner that is meaningful for positive health outcomes. To that end, we urge OIG to remove the monetary cap, and to instead rely on other combinations of safeguards proposed in the rule to produce meaningful protections against fraud and abuse involving patients and programs. That way, hospitals are not penalized for doing right by patients and communities. We also recommend that OIG expressly permit the VBE participant to delegate the furnishing of tools or supports through an entity acting on the VBE participant's behalf and under the VBE participant's direction.
Again, we thank CMS and OIG for your focus on these critical issues. Maryland's hospitals greatly appreciate the strides that both agencies have taken to carve out spaces where hospitals and physicians may continue to innovate to enhance care coordination, improve quality, and appropriately reduce costs under the Maryland Model.
President & CEO
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1/ For purposes here, we define gainsharing as the direct payment from hospitals to physicians of incentives that are based on hospital care cost and quality.
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The proposed rule can be viewed at: https://beta.regulations.gov/document/CMS-2018-0082-0394
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