Cardiologist: New bundled payment program 'adds another click,' real interoperability needed

Interoperability between health system information technology is needed for new federal bundled payment initiatives to work, according to a cardiologist and others preparing for implementation of reforms under the Medicare Access and CHIP Authorization Act, also known as MACRA.

On Monday, the Centers for Medicare and Medicaid mandated a new bundled payment directive for cardiac care and rehabilitation for 98 hospitals in metropolitan areas randomly selected by CMS.

The model, and another for comprehensive care for joint replacement in 67 hospitals already testing hip and knee replacement models, will be phased in over five years starting in July 2017. Both will qualify for incentives under MACRA's advanced alternative payment model starting in 2018.

[Also: CMS mandates new bundled payment program, will qualify as MACRA advanced payment model]

Last week at an American College of Cardiology meeting, everyone was talking about how to implement CMS's two payment models under MACRA, according to Glenn Hirsch, MD, associate professor of medicine and clinical director in the Division of Cardiovascular Medicine at the University of Louisville in Kentucky.

"People know it's coming," he said. "You have these large systems, on the hook for millions of dollars. People want to know how to meet the metrics."

Overall, Hirsch said he believes the change to value-based payment, including the new bundled models, is positive, as finances are a great motivator to integrate patient care and focus on quality and outcomes.

"In theory it's going to be a good thing," Hirsch said.

In practice, it's another straw on the back of physicians, or as Hirsch calls it, another keyboard click added to hundreds of clicks they are already mandates to perform.

It takes about 20 clicks and that many passwords for a doctor to access a note for a patient record, he said.

[Also: Marshfield, Contessa Health in Wisconsin form partnership on bundled payments for home care]

"It's just one more click. You wouldn't believe how many clicks it takes to get to a note," he said. "Personally I love medicine. When you add just one more click, just the 12th password to see something, just one more thing is very challenging."

CMS's Acting Administrator Andy Slavitt said something similar on Twitter this week. "15 minutes spent tapping on a keyboard is 15 minutes that can't be spent on patient care." he said.

Providers are not talking to one another across health systems, and sometimes within health systems, because of lack of IT interoperability as well as privacy concerns under HIPAA, Hirsch said.

Current analytics are made to mine data, not for provider workflow, he said.

"We can put in a new heart valve through your leg, yet it's hard to find out information about people across the street," Hirsch said of health systems located across from each other.

[Also: Enter MACRA: CMS chief Andy Slavitt says new law lets doctors be doctors]

Healthcare providers need to talk one another as people do in the real world, through social media, he said. What's needed is secure social media to connect all partners.

"We need simpler solutions to provide better care," Hirsch said. "People are not documenting appropriately."

Hospital systems need to collaborate with the government, other hospital systems and professional societies to get to high-quality, integrated care.

The Society of Thoracic Surgeons has offered its database for adult cardiac surgery. The clinical registry houses more than 5.9 million surgical records and information from over 90 percent of the groups that perform cardiac surgery in the United States.

"We believe that the STS National Database could facilitate physician-led, quality-based payment reform in the way that Congress intended," said STS President Joseph Bavaria, MD.

CMS has given the financial incentives to support collaboration, which could save, for instance, the expense of having a doctor order a second test because he does not have the results of one already done elsewhere.

Providers have already seen the gains in bundling orthopedics, Hirsch said.

"In the bigger picture," Hirsch said, "MACRA will blow up how we take care of patients."

A hospital's financial health is increasingly tied to these models, according to Susan Nedza, senior vice president of Clinical Outcomes Management at MPA Healthcare Solutions in Chicago.

Nedza is the former chief medical officer at CMS.

Alternative payment models for total joint replacement and cardiac care represent a significant contribution to their bottom lines, she said.

Providers will need to align quality and financial incentives with physicians and post-acute care providers.

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Nedza said providers shouldn't rely on historical performance for the target price as that's a moving target dependent on the performance of all participating providers. Systems should also ensure physicians, hospitals, and post-acute care providers commit to providing clinical information across transitions of care and understand how each contributes to quality and cost, as the joint replacement model covers until 90 days post-discharge. Also, Nedza said providers should know the patient population and use risk adjustment to identify true adverse outcomes, as well as understand the interaction between length of stay, emergency department utilization, readmissions and post-discharge deaths.

Also, avoid dependence on process measures that are not linked to improved quality or that drive up cost, she said, as many of the metrics currently measured for compliance and payment fail to predict adverse events.

"The bundled payments illustrate how the system is changing for the good," said Peter Orszag, former director of the Office of Management and Budget. "Secretary (Sylvia) Burwell has just made it vividly clear to everyone in health care that the days of paying for volume are ending."

Twitter: @SusanJMorse