CMS proposes new bundled payment models for high-quality cardiac, hip fracture care

Issue: September 2016

The CMS has proposed new bundled payment models for high-quality cardiac and hip fracture care as part of continuing efforts to reward quality care at a lower cost.

The agency has also proposed an incentive payment program to encourage more use of cardiac rehabilitation.

According to a notice of proposed rulemaking from the CMS, the new models will create strong incentives for hospitals to work with physicians and other providers to reduce complications and hospital readmission rates and speed patient recovery.

The cardiac-care provisions include procedures related to caring for patients who require CABG or treatment for MI.

Tom Nickels, executive vice president of the American Hospital Association, said in a statement that the association plans to analyze the proposals and work on improving the models to ensure that “they are reasonable and workable for patients”.

Nickels said in the statement that this is the third mandatory demonstration project from the agency in little more than a year. “Hospitals are under a tremendous burden to help ensure these complex models work for patients,” he said. “America’s hospitals are committed to improving care coordination thoughtfully and systematically in order to create better value for our patients and communities.”

Quality vs. quantity

The new policies include:

New bundled payment models for cardiac care and the extension of the current Comprehensive Care for Joint Replacement model to include other hip and femur fracture surgeries besides hip replacements.
A new model that incentivizes physicians to increase the use of cardiac rehabilitation.
A new pathway that allows physicians who participate in bundled payment models to receive payment incentives under the Quality Payment Program, an implementation of the Medicare Access and CHIP Reauthorization Act.

Under the new models, the hospital which admits the patient for care for a MI, CABG or hip or femur fracture surgery will be responsible for the cost and quality of care provided to the Medicare patient for their hospital stay and 90 days after discharge. Hospitals will be paid a fixed price for all treatment. If a hospital delivers quality care at a price below the target, then it receives money back based on a per-patient formula at the end of the model performance year. When the cost of treatment exceeds the target, the hospital is required to reimburse Medicare.

Richard A. Chazal

Patient first

Quality of care will be evaluated on hospital readmission rates, emergency room visit rates, amount of care deferred beyond the 90-day post discharge period, all-cause mortality rates, Hospital Consumer Assessment of Healthcare Providers and Systems satisfaction surveys and beneficiary surveys.

According to the CMS, the proposed models will also help reach the administration’s goal of 50% of traditional Medicare payments flowing through alternative payment models by 2018. The models are expected to roll out in July 2017 in hospitals in 98 geographic areas across the country. The proposed rule can be viewed in the Federal Register for 60 days and feedback can be given to the CMS.

“The American College of Cardiology supports the movement toward value-based care. Improving quality care and value are central to the ACC’s strategic plan,” Richard A. Chazal, MD, FACC, president of the ACC, said in a statement.

Steven Houser

However, Chazal said, “While we support the concept, it is important that bundled care models be carried out in such a way that clinicians are given the time and tools to truly impact patient care in the best ways possible. Changes in payment structures in health care can pose significant challenges to clinicians and must be driven by clinical practices that improve patient outcomes.”

Steven Houser, PhD, FAHA, president of the American Heart Association, said in a press release that “we believe that the movement towards value-based payment models may be a way to incentivize high quality, evidence-based care for patients. In the case of cardiac rehabilitation, the evidence for patient benefit could not be clearer: [Cardiac rehabilitation] reduces the risk of a future cardiac event, reduces hospital readmissions, and improves a patient’s overall quality of life. Unfortunately, we also know that [cardiac rehabilitation] remains greatly underutilized among eligible patients. We believe the Cardiac Rehabilitation Program Incentive Payment Model could be a significant step in the right direction to overcome this challenge by incentivizing providers to coordinate [cardiac rehabilitation] and ensuring that eligible patients have access to, participate in and adhere to evidence-based [cardiac rehabilitation] treatment plans.”

Chazal said the ACC remains optimistic that CMS will listen to feedback and allow enough time for implementation of the new models. Houser said the AHA will review the cardiac payment models and will work with the Department of Health and Human Services to design and test the cardiac rehabilitation payment model. – by Tracey Romero

Disclosure: Nickels is an employee of the American Hospital Association. Chazal and Houser report no relevant financial disclosures.

Editor’s Note: This article was updated on July 26, 2016 to add comments from the AHA.