Physician groups air concerns over timing for bundled payments rollout

The release of the final rule for implementation of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program certainly grabbed physicians’ attention, but hospitals are bracing for more regulations regarding bundled payments for cardiac and orthopedic care.

Physician groups are praising the Centers for Medicare and Medicaid Services for listening to their concerns that were raised when the proposed rule for MACRA was released back in the spring. Now, hospitals are hoping that the agency will listen to their concerns and, at the very least, push back the scheduled July 1, 2017, start of the programs.

The Comprehensive Care Joint Replacement (CJR) model for knee and hip replacement was launched April 1, and the proposal for changing and expanding the program was released four months later on July 25. The short time frame was something the American Hospital Association made note of in its comment letter, in which it argued that CMS has had little time “to garner, let alone apply, any lessons learned” so far with the program.

“We urge CMS, in the strongest possible terms, to refrain from expanding mandatory bundled payment models to other geographic areas or conditions before there has been enough time to assess the lessons learned under the existing models,” AHA Executive Vice President Thomas Nickels wrote in the organization’s letter to CMS Acting Administrator Andy Slavitt.

The AHA’s comment letter was one 178 CMS received before the Oct. 3 deadline. While that number may pale in comparison to the nearly 4,000 comments received for MACRA, Slavitt was openly campaigning for input on that rule. CMS reports that he appeared at several medical group conferences, including the American Medical Association House of Delegates meeting, and spoke to a combined audience of around 100,000 physicians.

The new bundled payment proposals include only a small fraction of the scope that MACRA covers, but in targeting orthopedic and cardiac care, CMS is looking to reduce costs on two of hospitals’ biggest income sources. In its fact sheet, the CMS noted that heart attacks and strokes result in more than $300 billion in healthcare costs annually.

The AHA and Federation of American Hospitals both agreed to the underlying principles behind the addition of hip- and femur-fracture surgery to the CJR bundles and the creation of bundles for heart attack, bypass surgery and cardiac rehabilitation. But, in addition to inpatient care, the payment bundles would extend the episode of care to include treatment received in the 90 days after discharge. This led the FAH to ask CMS for an additional six months so its members could build the clinical, legal, financial and quality infrastructure needed to launch the new model as well as provide time to redesign their clinical care models.

The American Medical Group Association (AMGA) noted in its comment letter that the CMS needs to evaluate and publicize efforts at care redesign because “unfortunately, how hospitals, post-acute providers and physician practices redesign care or innovate is not made known.”

The launch of the surgical hip/femur fracture treatment (SHFFT) model would cover the same 67 metropolitan areas as the existing hip- and knee-replacement bundles that have already been implemented. But the cardiac bundles will be launched in 98 randomly selected areas that have yet to be named. Rural counties are excluded from the model.

But, the proposed rule would put small hospitals at risk, from the perspective of Dr. Linda Gillam, chairwoman of the American College of Cardiology’s Partners in Quality Committee. Small hospitals that receive heart-attack patients could be responsible for the patients’ episode of care even if they transfer the patient to a larger facility shortly after admission.

“It should be the receiving hospital that’s on the hook for the bundle,” said Gillam, chairwoman of the cardiovascular medicine department at Morristown (N.J.) Medical Center, explaining that the rule may incentivize hospitals to keep patients in the emergency department rather than formally admit them while stabilizing their condition.

This is just one of the unintended consequences that may result because of the way the proposed rule is written, she said.

Another involves a critically ill patient who is dying from something other than heart disease and is brought to an emergency department with a heart attack. As proposed, Gillam said the rule may incentivize hospitals to provide aggressive cardiac treatment when palliative care may be more beneficial to the patient.

In its comment letter, the ACC noted the benefit to limiting the bundled payment program to patients who have heart attacks caused by blockages of the artery, or STEMI (ST-elevation myocardial infarction), compared to NSTEMI (non-ST-elevation myocardial infarction) heart attacks brought on by other causes.

Gillam noted that STEMI heart attack patients are easily identifiable — just like the individuals in the first bundled program. “Either you had your knee replaced or not,” she said.

The ACC comment letter notes that limiting the payment model to the more “clinically homogenous” STEMI patient population will provide CMS with more meaningful comparisons and a clearer evaluation of how episode payment models are affecting patient care and outcomes.

Both the ACC and AMGA noted their enthusiastic support for the cardiac rehabilitation bundled payment model, with the AMGA calling rehab “woefully underutilized” and noting how only 35 percent of heart attack patients receive this treatment — a pattern it said, that has not improved over the past two decades.

Since heart disease is the nation’s leading cause of death, Gillam said it was an appropriate target for CMS quality-improvement and cost-lowering efforts, but “target” may be the wrong word to use.

“Targeting implies you have bulls-eye on your back and someone’s out to get you,” Gillam said, adding that there is large database showing large variations in the quality and cost of heart disease care.

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