CMS proposed the Transforming Episode Accountability Model, a new five-year, episode-based payment model affecting orthopedics and spine, in April and the final rule is expected to drop soon.
The proposal requires select acute care hospitals to coordinate care for patients in the traditional Medicare model undergoing surgical procedures and assume responsibility for the cost and quality of care for the first 30 days after leaving the hospital. Lower joint replacements, spinal fusions, and surgical hip femur fracture treatment are included in the proposed model.
CMS pitched giving hospitals a target price representing most Medicare spending for the episode of care, covering inpatient and outpatient surgery as well as skilled nursing facility stays and follow-up visits. Participating hospitals would need to refer patients to primary care services to support continuity of care long term.
The model would start in January 2026 and hospitals would be selected based on geographic region. There are three tracks proposed: first, with no downside risk and lower levels of reward for the first year; track two includes lower levels of risk and reward for safety net hospitals and other institutions; and track three includes a higher level of risk and reward.