June 10, 2024
Mehmet Oz, MD
Administrator
Centers for Medicare & Medicaid Services
U.S. Department of Health and Human Services
ATTN: CMS-1833-P
P.O. Box 8013 Baltimore, MD 21244-1850
Submitted electronically via www.regulations.gov
Subject: CMS-1833-P Hospital Inpatient Prospective Payment Systems for Acute
Care Hospitals Policy Changes and Fiscal Year (FY) 2026 Rates; Quality
Programs Requirements; and Other Policy Changes
Dear Dr. Oz:
On behalf of the American Association of Neurological Surgeons (AANS) and the Congress of
Neurological Surgeons (CNS), representing more than 4,000 neurosurgeons in the United States,
we appreciate the opportunity to comment on the provisions of the above-referenced notice of
proposed rulemaking.
MS-DRG CHANGES
Neurostimulator Implants
We appreciate CMS moving all intracranial neurostimulator implants (DBS and epilepsy) to a
new MS-DRG group that better reflects the associated costs for these patients. As the agency’s
data show, the care of these patients often exceeds the average costs for cases in their existing
MS-DRG assignments. CMS states that some of these cases will still incur costs that exceed
the average costs of the MS-DRGs 021 and 022, which do not have a Major Complication and
Comorbidity (MCC) designation. We request that CMS continue its effort to better align MS-DRG
reimbursement and costs of care by ensuring that the reimbursement levels of these newly
revised MS-DRGs adequately cover the costs of care for these complex patients who receive
intracranial implants. The appropriateness of the FY 2026 reimbursement levels for these
revised DRGs will need to be closely scrutinized. It should be strongly considered for analysis to
determine possible further upward revisions in FY 2027, if the values set for FY 2026 are
inadequate.
TRANSFORMING EPISODE ACCOUNTABILITY MODEL (TEAM)
The AANS and the CNS recognize that Medicare beneficiaries undergoing a surgical procedure
either in the hospital or as an outpatient may experience fragmented care that can lead to
complications in recovery, avoidable hospitalizations, and other high costs. As such, we
support efforts to improve care transitions and to incentivize care coordination and higher value
care across the inpatient and post-acute care settings. However, the AANS and CNS continue
to believe that TEAM is fundamentally flawed, as it is primarily focused on cost containment,
despite being framed as a quality improvement initiative.
Mandatory Participation
The AANS and the CNS strongly oppose compulsory participation in alternative payment and
delivery models. CMS must maintain voluntary participation models that allow hospitals and
surgeons to tailor bundled and other payment reforms to their specific patient populations,
practice settings, administrative capabilities, and resources. While mandatory models can
address participation challenges inherent to voluntary models, they also ignore real barriers that
some providers face in terms of building the resources and infrastructure needed to succeed in
these models. These include staff shortages, insufficient or otherwise non-representative
patient volumes, and a lack of negotiating power within their community, all of which make it
more difficult to provide higher value, coordinated care. Despite years of attempts, a major lack
of access to interoperable health information technology systems and robust data analytics
remains. In this environment, what providers need most is more flexibility, better support and
guidance, and stronger incentives — not a restrictive mandate that could drive participant
hospitals to skimp on clinically necessary care and avoid higher-risk patients in order to meet
price and quality targets. Mandatory models should not force hospitals and health systems that
have already adopted their own innovative ways to provide high-value care to alter their care
processes in ways that might reverse progress made in terms of patient outcomes and
efficiencies.
Ultimately, if an alternative payment or delivery model is appropriately contemplated — with
the active involvement of physicians in its design, implementation, and evaluation — then
physicians will willingly participate, negating the need for mandatory participation.
Limited Role of the Physician
The AANS and the CNS are disappointed that CMS has not directly consulted physicians who
are directly impacted by this model, including our spine surgeon members. It is critical that
CMS directly engage relevant practicing physicians in model development and
implementation, including defining appropriate participation parameters, episode triggers,
quality measures, and risk adjustments, as well as methods for assessing model success over
time. When CMS fails to engage front-line physicians, it raises questions about whether the
agency is genuinely interested in higher-quality care or whether its sole goal is cost reduction.
We ask CMS to maintain, as a guiding principle, that hospitals do not perform surgical
procedures or determine if such procedures are clinically indicated; surgeons do.
We are equally concerned that CMS fails to provide physicians with any autonomy under TEAM
and fails to recognize the leading role that physicians play in an episode. Surgical patients
look to their surgeon, not the hospital, as the ultimate authority on their perioperative care. Yet
under TEAM, only hospitals may be considered “participants,” while it is at the hospital’s
discretion to engage with or form a financial arrangement with “TEAM collaborators,” such as
physicians. This differs from the BPCI-A, which allows physician group practices, as well as
hospitals, to take on leading roles through clearly defined partnership policies. We are
concerned that the TEAM approach could result in perverse incentives that encourage hospitals
to make care decisions that are not in the best interest of the patient — especially since this
model includes elective and non-elective cases.
Further, hospital administrators with no clinical experience could be empowered by this model
to alter hospital operations to optimize their facility’s short-term performance metrics at the
expense of quality and cost after the measurement period. This increases the risk of cherry-
picking, lemon-dropping, and other forms of favorable selection that risk-adjustment
methodologies may not capture. In other situations, hospitals might cut necessary post-acute
spending, which can impact patient outcomes and longer-term costs. Involving relevant
clinicians who are directly accountable for the patient’s care would minimize these risks.
We also believe that the current TEAM framework runs the risk of sidelining independent
specialists— who ultimately are the main factor in the decision-making process for the patient
to undergo the procedures being measured—and accelerating healthcare consolidation, which
could drive up costs further, stifle innovation and local experimentation, and erode patient
access to specialty care.
A 2024 analysis by the Congressional Budget Office found that ACOs led by independent
physicians generated substantially larger Medicare savings than those led by hospitals.
The report noted that independent physician-led ACOs have clear financial incentives to reduce
hospital care to lower spending, unlike hospital-led ACOs, which earn more revenue when
patients are admitted. Hospitals also have less direct control over what services patients
receive.
In light of these concerns and findings, we reiterate our request that CMS must adopt policies
under TEAM that:
- Require hospitals to integrate clinically relevant specialties into team leadership and
governance roles to ensure the provision of appropriate care, and to ensure that
savings result from improved efficiencies, rather than simply favorable selection or
gaming at the expense of the patient. - Require hospitals to pass on a proportional portion of the shared savings generated
under this model to the surgeons responsible for treating patients that trigger the
episodes. The distribution of such savings should not be left to the hospital’s
discretion. This better aligns with financial incentives. - Ensure that physicians have adequate resources and flexibility under the model to
deliver services that result in good outcomes for all types of patients and to ensure that
physicians are not directly or indirectly at risk for outcomes or costs they cannot
control. Unfortunately, under some of the most widely implemented models to date,
such as Shared Savings Program ACOs, physicians—particularly specialists—do not have
a leading role. As a result, they have little control over decisions related to clinical
appropriateness, patient selection, referrals, and performance measurement.
…
Read full letter here
