In a final rule issued on Nov. 30, CMS finalized changes to several mandatory bundled payment programs, canceling two surrounding hip fractures and cardiac care and reducing requirements in a joint replacement bundle.

CMS had first proposed cancelling the Advancing Care Coordination through Episode Payment Models (EPMs) and Cardiac Rehabilitation Incentive (CRI) models in August after several delays to the programs’ start dates. The Comprehensive Care for Joint Replacement (CJR) model will remain mandatory for some providers, but the number of mandatory geographic areas included was reduced from 67 to 34 in the rule, with voluntary participation for “low volume and rural hospitals” in all 67 areas

“While CMS continues to believe that bundled payment models offer opportunities to improve quality and care coordination while lowering spending, we believe that focusing on developing different bundled payment models and engaging more providers is the best way to drive health system change while minimizing burden and maintaining access to care. We anticipate announcing new voluntary payment bundles soon,” CMS Administrator Seema Verma, MPH, said in a statement.

Stakeholder groups were largely supportive of the moves, saying the future bundled payment programs should be voluntary. The Federation of American Hospitals argued mandatory programs were always outside of the CMS’s authority and would have to be enacted by Congress.

There were concerns, however, from groups like the American Hospital Association that cancelling the bundles leaves too few avenues for providers to participate in the Advanced Alternative Payment Models (AAPMs) track of the Quality Payment Program. The American College of Cardiology and others said they would work on crafting new programs which could qualify as AAPMs and the associated 5 percent bonus payment.

Future payment experiments may be driven by comments stakeholders have made in recent months. Soon after the proposed rule was released, CMS solicited comments from groups for how to take a “new direction” on payment models introduced through the Center for Medicare and Medicaid Innovation (CMMI). Responding organizations made a long list of recommendations—including focusing only on voluntary, small-scale programs and changing its standard of downside risk.