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Federal Register / Vol. 86, No. 154 / Friday, August 13, 2021 / Rules and Regulations participation decisions made by ACOs in similar positions entering PY 2021.
We estimate that the flexibility would prevent between 20 to 30 ACOs that would otherwise be required to transition to performance-based risk in PY 2022 from dropping out of the Shared Savings Program.
Additionally, we estimate that between 60 to 80 ACOs that would otherwise attempt the transition to performance-based risk would, out of caution, opt to stay in a one-sided model in PY 2022 that is BASIC track Level A or B despite the opportunity to graduate to a higher level of potential reward under BASIC track Levels A and B, ACOs share at most 40 percent of savings, whereas BASIC
track Levels C, D, and E allow for greater upside potential with a maximum sharing rate of 50 percent. The net effect of offering this flexibility is estimated to be a $90
million reduction in Federal spending, with the reduction ranging from $50 to $140
million. The estimated impact is roughly evenly split between net savings generated by ACOs that would otherwise have terminated their participation in the program absent the flexibility and reduced shared savings payouts to ACOs that elect to remain at the lower sharing rates in Levels A or B of the BASIC track despite the fact they would have ultimately earnedas a groupmore shared savings had they transitioned to a risk arrangement in Level C, D, or E of the BASIC
track. Although we have estimated the impact of this policy over the single performance year for which it would expand certain ACOs participation options, it is possible there could be secondary impacts over a longer time period. However, we do not believe the longer run potential effects are readily quantifiable. On one hand, the final policy could allow certain ACOs to delay making more aggressive care delivery changes if they expect CMS is likely to continue to offer risk-free participation in the program in future rulemaking, as has been the case for two successive rules the May 8, 2020 COVID19 interim final rule with comment period and this FY 2022 IPPS/
LTCH PPS final rule. On the other hand, the final policy could give other ACOs additional time to grow in confidence in their ability to manage the transition to risk, while at the same time finding stability in their operations after the disruption from the COVID19 PHE. ACOs in the latter category may then find longer-term success including driving lower net spending for the program that might have otherwise been curtailed had the ACO been forced to transition to performance-based risk for PY 2022. These two scenarios illustrate potential countervailing longer run impacts from the freeze for PY 2022, and while we have not attempted to estimate a net impact across the mix of such possible scenarios for ACOs impacted by this policy, we assert that offering ACOs in the BASIC track the opportunity to freeze their level of participation for PY 2022 increases the chance that the program could sustain a larger mix of participants and this outcome outweighs the risk that certain ACOs might be marginally slower to make efficiencyrelated changes in care delivery.
We did not receive any comments regarding the discussion of the impacts of
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this policy in the proposed rule. As discussed in section X.B. of the preamble of this final rule, we are finalizing the proposed policy without modification. Furthermore, our projection of the impact of this change has not changed from what was previously communicated in the proposed rule.
I. Effects of Changes in the Capital IPPS
1. General Considerations As discussed, in section III.A of the Addendum to this final rule, we used claims from the March 2020 update of the FY 2019
MedPAR file and provider data from the March 2020 update of the Provider Specific File PSF for purposes of determining the capital Federal rate for FY 2022. Consistent with these policies, for the impact analysis presented in this section, we used data from the March 2020 update of the FY 2019
MedPAR file and the March 2020 update of the PSF that was used for payment purposes.
Although the analyses of the changes to the capital prospective payment system do not incorporate cost data, we used the March 2021 update of the hospital cost report data FYs 2017 and 2018 to categorize hospitals.
Our analysis has several qualifications and uses the best data available, as described later in this section.
Due to the interdependent nature of the IPPS, it is very difficult to precisely quantify the impact associated with each change. In addition, we drew upon various sources for the data used to categorize hospitals in the tables. In some cases for instance, the number of beds, there is a fair degree of variation in the data from different sources.
We have attempted to construct these variables with the best available sources overall. However, it is possible that some individual hospitals are placed in the wrong category.
Using cases from the March 2020 update of the FY 2019 MedPAR file, we simulated payments under the capital IPPS for FY 2021
and the payments for FY 2022 for a comparison of total payments per case. Shortterm, acute care hospitals not paid under the general IPPS for example, hospitals in Maryland are excluded from the simulations.
The methodology for determining a capital IPPS payment is set forth at 412.312. The basic methodology for calculating the capital IPPS payments in FY 2022 is as follows:
Standard Federal rate DRG weight
GAF COLA for hospitals located in Alaska and Hawaii 1 + DSH adjustment factor + IME adjustment factor, if applicable.
In addition to the other adjustments, hospitals may receive outlier payments for those cases that qualify under the threshold established for each fiscal year. We modeled payments for each hospital by multiplying the capital Federal rate by the GAF and the hospitals case-mix. Then we added estimated payments for indirect medical education, disproportionate share, and outliers, if applicable. For purposes of this impact analysis, the model includes the following assumptions:
The capital Federal rate was updated, beginning in FY 1996, by an analytical framework that considers changes in the prices associated with capital-related costs
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and adjustments to account for forecast error, changes in the case-mix index, allowable changes in intensity, and other factors. As discussed in section III.A.1. of the Addendum to this final rule, the update to the capital Federal rate is 0.80 percent for FY
2022.
In addition to the FY 2022 update factor, the FY 2022 capital Federal rate was calculated based on a GAF/DRG budget neutrality adjustment factor of 1.0004, a budget neutrality factor for the lowest quartile hospital wage index adjustment and the 5 percent cap on wage index decreases policy of 0.9974, and an outlier adjustment factor of 0.9471.
2. Results We used the payment simulation model previously described in section I.I. of Appendix A of this final rule to estimate the potential impact of the changes for FY 2022
on total capital payments per case, using a universe of 3,195 hospitals. As previously described, the individual hospital payment parameters are taken from the best available data, including the March 2020 update of the FY 2019 MedPAR file, the March 2020
update to the PSF, and the cost report data for FYs 2017 and 2018 from the March 2021
update of HCRIS. In Table III, we present a comparison of estimated total payments per case for FY 2021 and estimated total payments per case for FY 2022 based on the FY 2022 payment policies. Column 2 shows estimates of payments per case under our model for FY 2021. Column 3 shows estimates of payments per case under our model for FY 2022. Column 4 shows the total percentage change in payments from FY 2021
to FY 2022. The change represented in Column 4 includes the 0.80 percent update to the capital Federal rate and other changes in the adjustments to the capital Federal rate.
The comparisons are provided by: 1
Geographic location; 2 region; and 3
payment classification.
The simulation results show that, on average, capital payments per case in FY
2022 are expected to increase as compared to capital payments per case in FY 2021. This expected increase overall is primarily due to the 0.80 percent update to the capital Federal rate for FY 2022 and the reinstatement of the imputed floor in a non-budget neutral manner. The increase in capital payments due to these changes was partially offset by an estimated decrease in capital DSH
payments due to the estimated increase in the number of hospitals that reclassify from urban to rural under 412.103. We approximate that there are 82 hospitals classified as urban for payment purposes and receiving capital DSH payments in FY
2021, that will be classified as rural for payment purposes and will not receive capital DSH payments in FY 2022. Under 412.320, in order to receive capital DSH
payments a hospital must be located in an urban area for payment purposes and have 100 or more beds, and paragraph a1iii specifies that the geographic classification of an urban hospital that is reclassified as rural as set forth in 412.103 is rural. In general, regional variations in estimated capital payments per case in FY 2022 as compared to capital payments per case in FY 2021 are
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