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CMS plans to cancel cardiac payment models
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CMS has proposed canceling cardiac episode payment models and a cardiac rehabilitation incentive payment model that were originally set to begin in 2018, according to a document published in the Federal Register.
“We believe that requiring hospitals to participate in additional episode payment models at this time is not in the best interest of the agency or the affected providers,” the agency stated in the document. “Many providers are currently engaged in voluntary initiatives with CMS, and we expect to continue to offer opportunities for providers to participate in voluntary initiatives, including episode-based payment models.”
The models were originally designed as mandatory payment models to observe the effects of bundling care and incentivizing a higher quality of care. After receiving numerous public comments on items such as the CABG episode payment model and the design of cardiac rehabilitation incentive payment model waivers, CMS decided it would be best to cancel the models rather than redesign certain areas as the start date approaches.
CMS wrote that providers will not have additional costs from the cancellation of episode payment models and the cardiac rehabilitation incentive payment model. Beneficiaries will also not be affected, as they will still have freedom to get health care services from any clinician or organization that is qualified within the Medicare program, according to the agency.
“For patients who suffer from a [MI] or need bypass surgery, cardiac rehabilitation is vitally important to their recovery, yet many do not take advantage of rehab programs once they leave the hospital because they must contend with a variety of barriers, such as community demographics and geographic location,” John Warner, MD, president of the American Heart Association, told Cardiology Today. “The [Cardiac Rehabilitation] Incentive Payment Model was designed to encourage and support these patients in utilizing these services more frequently. By cancelling this model, CMS has unfortunately added one more obstacle to the list making it more difficult for these patients to get access to the affordable cardiac rehab they need to return to everyday life.”
“The American College of Cardiology will continue to work with CMS on opportunities for clinicians to participant meaningfully in advanced alternative payment models,” Mary Norine Walsh, MD, FACC, president of the ACC, medical director of the heart failure and cardiac transplantation programs and director of nuclear cardiology at St. Vincent Heart Center in Indianapolis and a member of the Cardiology Today Editorial Board, said in a press release. “As we move from volume-based care to value-based care, the path forward is challenging, and we must work together to find solutions.”
The Society for Cardiovascular Angiography and Interventions Foundation issued a statement that it “will continue to be actively engaged with the CMS with a goal of crafting an [advanced alternative payment model] that could support potential cost-savings, while improving the quality of delivered care.” – by Darlene Dobkowski
Reference:
Office of the Federal Register. Cancellation of Advancing Care Coordination through Episode Payment Models and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model (CMS-5524-P). Aug. 15, 2017. Available at: www.federalregister.gov/public-inspection/current. Accessed Aug. 16, 2017.
Disclosure: Walsh and Warner report no relevant financial disclosures.
Perspective
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W. Douglas Weaver, MD
It is not surprising that they pulled back on some of the joint replacement. Of note, a third of the cost associated with joint replacement is post-acute care, which in the bundle requires the hospital and physicians now to manage these patients after they leave the hospital — a new and challenging segment of care for these providers. The joint model has taken years to implement, and CMS has repeatedly pushed the timelines back. It hasn’t been the easiest thing for CMS to implement in a fair way to providers, and there are probably other and possibly easier opportunities for CMS.
For acute MI and with CABG, post-acute care is a small part of the total cost. Therefore, coming up with substantial savings, essentially further reducing inpatient costs, is more limited than it is for joint replacement. The length of stay for both of these conditions has been reduced substantially in the last 5 or 6 years. It is not clear to me how successful a bundle payment would have been, as the management of these patients is pretty efficient already.
CMS stepping back does not mean a stepping away. There are so many things that CMS has ongoing right now, and as they mentioned in the announcement, this gives them additional time to increase other voluntary efforts, which they believe may be even more effective than mandatory ones.
Trying to rein in costs is not going to go away. Pay-for-performance is still there, accountable care organizations are still there and the Medicare Access and CHIP Reauthorization Act is not going away. MACRA has many of us very worried, and that is focused on costs and resource utilization for the Medicare beneficiaries.
From a clinical perspective, the incentive for increasing the use of cardiac rehabilitation would be good. There are data that have been accumulated in patients with HF as well as post-MI showing that cardiac rehabilitation can improve the outcomes and quality of life in these individuals.
In cardiology, we are all concerned about cost, efficiency and improving continuity of care. CMS has done a great job at bringing these to the top of mind, but we also want to do things that are going to make major improvements in the care of patients. If we are performing tasks just to be part of a program that isn’t going to have a big yield as far as cost savings and improved care, it’s difficult to get enthusiastic to do the needed work.
The voluntary efforts around HF management are very important. HF is one of the largest costs of hospitalization in our and many other Western countries, and there have been voluntary demonstration projects aimed at these patients. The opportunity is far greater in HF than it is in other cardiac situations. It could yield in better coordinated long-term care in these individuals because so many recent admissions for HF result in early readmission soon after discharge confused patients about changes in medications. Splintered care is being delivered by both cardiology and primary care providers, and the not uncommon use of extended-care facilities. Ideal coordination is lacking generally.
This seems like the place to put the effort, as it is challenging and yet has the opportunity to improve outcomes in these individuals.
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