Although hospitals have improved care delivery in their early experience with CJR, certain types of hospitals are likely to face formidable challenges under the new mandatory models.

Jan. 3—More than 1,100 hospitals will be required to participate in new Medicare cardiac care payment bundles under final rules issued over the objections of some providers and despite opposition from the nominee to lead the U.S. Department of Health and Human Services (HHS).

The Centers for Medicare & Medicaid Services (CMS) issued final rules shortly before Christmas to establish the Acute Myocardial Infarction (AMI) Model and the Coronary Artery Bypass Graft (CABG) Model at 1,120 hospitals by July. Another new program—the Surgical Hip and Femur Fracture Treatment (SHFFT) Model—was added at 860 hospitals that are participating in the existing Comprehensive Care for Joint Replacement (CJR) model, which launched in April 2016, a CMS fact sheet stated.

The finalization of the latest mandatory payment models followed calls for delay by many provider advocates. Those advocates had a mixed reaction to the final rules.

Tom Nickels, executive vice president for the American Hospital Association (AHA), noted that the cardiac care bundle was the second mandatory demonstration project finalized by CMS in just 15 months.

“This is too much, too soon,” Nickels said in a written statement. “Regrettably, at the same time, the agency finalized its plans to expand and further complicate its existing mandatory hip and knee bundled payment model less than a year after it began, and before fully evaluating its results.”

The AHA is concerned about requiring hospitals to participate in complex payment models before CMS has proven that the models benefit patients.

In contrast, Premier, a hospital quality improvement company, supported the addition of new advanced alternative payment models (APMs), including the new models for cardiac and orthopedic procedures.

“Bundled payment models have been shown to incent care coordination, quality improvement and cost containment,” Blair Childs, a senior vice president for Premier, said in a written statement. “Moreover, we commend CMS for recognizing that these models need to conform with the definition of advanced alternative payment models, as outlined in [the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)], for the purposes of allowing qualified professionals to earn a 5 percent bonus.”

Under the final rules, clinicians participating in the new cardiac and orthopedic payment models earn MACRA incentive payments as soon as performance year 2018 if they work with hospitals in the Advanced APM path. Clinicians in CJR can earn incentive payments as soon as performance year 2017.

Bundle Experience

François de Brantes, vice president and director of the Altarum Center for Payment Innovation, said hospitals have demonstrated an ability to manage bundles in several previous demonstration projects and pilots. Those facilities, physicians, and post-acute care providers have reengineered care in ways that can improve outcomes.

“So I’m not really concerned about provider ability to manage patients covered under a bundle,” de Brantes said in emailed comments.

However, he worries about the mandatory cardiac bundle’s “perverse incentives,” which could come at the expense of patient care.

“In addition to the lack of severity adjustment, there is an incentive to migrate outpatient [percutaneous coronary interventions] to inpatient—that’s good news for hospitals but bad news for patients—and the incentive to admit patients with mild AMIs that can be treated outpatient in order to trigger an AMI bundle,” de Brantes said. “That’s also good news financially for the hospitals but bad news for patients.”

Hospitals in CJR saw some early improvements in patient outcomes, according to industry advisers. For instance, fewer patients were sent to skilled nursing facilities (SNFs), with higher numbers of lower-acuity patients instead sent home with the assistance of home health agencies.

Outlook Uncertain

AHA plans to continue to urge CMS to designate new bundled payment programs as voluntary, but staff were unavailable to clarify whether the association will urge the incoming administration to reverse the coming mandatory models.

Some industry advisers have noted that Rep. Tom Price (R-Ga.), whom President-elect Donald Trump nominated as secretary of HHS, does not support mandatory models. Price led 179 lawmakers who wrote CMS in September to urge a halt to the mandatory payment models, such as CJR and the cardiac bundles.

Various hospitals, including academic medical centers, may struggle with the mandatory cardiac bundles, de Brantes said.

“I would think that any facility that attracts high-risk patients would be concerned by the almost complete lack of adjustment for the severity of patients,” de Brantes said.

Also finalized was the Cardiac Rehabilitation (CR) Incentive Payment Model, which continues usual Medicare payments to all providers and suppliers and awards incentive payments to hospitals at the end of a model performance year, depending on beneficiaries’ utilization of CR or intensive CR services. About 1,320 hospitals will be in the model.

The final rules also launched a new Medicare accountable care organization (ACO) model, Track 1+, which will have less downside risk than Tracks 2 and 3 of the Medicare Shared Savings Program. The new model aims to encourage more practices, especially small practices, to advance to performance-based risk, according to CMS.

The model drew some early support from provider advocates.

“The vast majority of ACO participants are excluded from the Advanced Alternative Payment models, but if done correctly, Track 1+ will serve as an on-ramp for providers to move toward increased risk sharing,” Donald Fisher, PhD, president and CEO of AMGA, said in a written statement.


Rich Daly is a senior writer/editor in HFMA’s Washington, D.C., office. Follow Rich on Twitter: @rdalyhealthcare

Publication Date: Tuesday, January 03, 2017