CMS Seeking Comments for Abandoning Cardiac Bundles and Limiting CJR Model

The Proposed Rule change posted to the Federal Register on August 10, 2017 indicates the Centers for Medicare and Medicaid Services (CMS) will rescind the regulations governing two mandatory bundled payment programs, the Advancing Care Coordination through Episode Payment Models (EPMs) and Cardiac Rehabilitation Incentive (CRI) Payment Models, which were scheduled to start in 2018.  It also proposes to revise certain aspects of the Comprehensive Care for Joint Replacement (CJR) Model, including:

• Giving certain hospitals selected for participation in the CJR model a one-time option to choose whether to continue their participation in the model;
• Providing technical refinements and clarifications for certain payment, reconciliation and quality provisions; and
• Increasing the pool of eligible clinicians that qualify as affiliated practitioners under the Advanced Alternative Payment Model (APM) track.

The August 14, 2017 edition of Cardiovascular Business published the article, “Cardiac Bundles to be Canceled by CMS,” that reported the same bundles have already been delayed twice since Health and Human Services Secretary Tom Price, MD, and CMS Administrator Seema Verma, MPH, took the reins at the agencies. Both have been critical of making bundled payments mandatory, with Verma saying in her confirmation hearing that new payment models should be expanded more gradually.

Price, an orthopedic surgeon, was the lead author of a letter to CMS in 2016 criticizing the mandatory cardiac bundles and the expansion of a joint replacement bundle, saying the moves would lead to providers consolidating and turning away Medicare beneficiaries. “Medicare providers and their patients are blindly forced into high-risk government-dictated reforms with unknown impacts,” he wrote. “Any true medical experiment requires patient consent. However, patients residing in an affected geographical area will have no choice about their participation.”

Some of Price’s concerns have been countered by research. An August 2016 analysis by Avalere Health, a leading Washington DC-based healthcare consulting firm, said that 85 percent of the hospitals required to participate in the cardiac bundles would not experience gains or losses greater than $500,000 per year. Institutions with spending already far above the regional average would face the heaviest losses.

The elimination of the cardiac bundles would remove a path for practices to qualify for the 5 percent bonus in 2019 under the APM track introduced by the Medicare Access and Children’s Health Insurance Program Reauthorization Act (MACRA).

On August 16, 2017, Becker’s Hospital CFO Report outlined eight things that are key components of the proposed rule change in their article, “CMS Cancels Cardiac Bundles, Scales Back CJR Model: 8 Things to Know.”

1. CMS sent a proposed rule to the Office of Management and Budget last week. The title of the rule indicated CMS would cancel mandatory bundled payment initiatives for heart attacks, bypass surgery, and hip and femur fractures. Details on the changes were revealed on August 15, 2017 when the proposed rule was made public.
2. The proposed rule would cancel the mandatory bundled payment program for heart attacks and bypass surgeries as well as the cardiac rehabilitation payment model, which is intended to test whether a payment incentive can increase the utilization of cardiac rehabilitative services.
3. The proposed rule would eliminate mandatory bundling for hip and femur fracture treatment under the Comprehensive Care for Joint Replacement program.
4. The cardiac bundled payment models and expansion of the CJR program are slated to begin Jan. 1, 2018.
5. The proposed rule would scale back the existing CJR model. Under the proposed rule, the CJR program would be mandatory for hospitals in 34 of the 67 geographic areas chosen for the program. The CJR model would continue on a voluntary basis in the other 33 geographic areas. The proposed rule would also make participating in the CJR model voluntary for all low volume and rural hospitals in the 67 areas.
6. “Changing the scope of these models allows CMS to test and evaluate improvements in care processes that will improve quality, reduce costs, and ease burdens on hospitals,” said CMS Administrator Seema Verma. “Stakeholders have asked for more input on the design of these models. These changes make this possible and give CMS maximum flexibility to test other episode-based models that will bring about innovation and provide better care for Medicare beneficiaries.”
7. Ashley Thompson, the American Hospital Association’s senior vice president for public policy analysis and development, said the AHA is concerned cancellation of the bundled payment models could cause problems for provider organizations that have spent valuable resources to implement these programs.
8. CMS will accept comments on the proposed rule until October 16, 2017.

Chris Garcia, CEO of Remedy Partners, said his organization had forecasted similar hurdles due to the bundles’ mandatory nature, as well as how complex cardiac care can be.

“We were not surprised that the mandatory models were running into trouble. Cardiac care is very complicated. So many specialists will touch a patient during a cardiac episode. We had heard from our cardiology partners and they said, ‘What are they talking about? This is crazy.’ The amount of effort CMS has put into the models so far was really the only surprising aspect to the proposed cancellation,” Garcia said.

The models were originally slated to begin in July 2017, but provisions of the final rule—including the start date—were delayed multiple times over the past year to give the new administration a chance to review them.

Those who are interested in commenting on the proposed rule that cancels the EPMs and CRI incentive payment model and to rescind the regulations governing these models must respond by 5:00 pm EDT on or before October 16, 2017.

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Phil C. Solomon is the publisher of Revenue Cycle News, a healthcare business information blog and serves as the Vice President of Marketing Strategy for MiraMed, a healthcare revenue cycle outsourcing company.  As an executive leader, he is responsible for creating and executing sales and marketing strategies which drive new business development and client engagement. Phil has over 25 years’ experience consulting on a broad range of healthcare initiatives for clinical and revenue cycle performance improvement.  He has worked with industry’s largest health systems developing executable strategies for revenue enhancement, expense reduction, and clinical transformation. He can be reached at [email protected]

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