Healthcare orgs ask CMS for changes to cardiac bundled payment programs ahead of rollout

Two months after The Centers for Medicare and Medicaid Services asked for comments on its bundled payment plan for cardiac treatment, major healthcare organizations are weighing in on fixes they think the program needs.

The Healthcare Information and Management Systems Society this week called for changes to the program that would enhance transparency and broaden the inclusion of new technologies in services related to episode payment models. HIMSS is also pushing for streamlining data-gathering and reporting in order to lighten the burden placed on participating clinicians.

However, other major healthcare organizations like the Federation of American Hospitals have told CMS it should not rush into new bundled payment models when the ones currently in place are still in their infancy.

The Comprehensive Care for Joint Replacement Model began earlier this year, which introduced bundled payments for certain hip and knee replacements. More than 1,400 providers are currently participating in bundles through Medicare's Bundled Payments for Care Improvement initiative.

[Also: Cardiac bundled payments could yield big winners and losers]

Under the proposed episode payment models, the hospital in which a patient is admitted for a heart attack, bypass surgery or surgical hip/femur fracture treatment would be accountable for the cost and quality of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days after discharge. Once the models are fully in effect, participating hospitals would be paid a fixed target price for each care episode, with hospitals that deliver higher-quality care receiving a higher target price, according to CMS' website.

Focusing on transparency, HIMSS said disclosure of partner contracting should be a requirement under the bundled payment models, which means hospitals would have to prove they have all the necessary contracts in place with all providers that will play a role in any episode of care, including post acute-care providers. Not having those contracts could lead some physicians to opt-out of participating.

"HIMSS members reported that there have been many instances where some post-acute care providers have been reluctant to negotiate contracts because they want to avoid any additional payment requirements under these kinds of arrangements. Including partner contract disclosure as a rulemaking requirement should help ease those concerns," HIMSS said in their official comments.

The group, which also owns Healthcare Finance, also pushed for full disclosure of the total bundled payment amount as well the amounts distributed to each participant in the patient's care, suggesting that an electronic tool involving a "standardized methodology" could be useful in comparing costs so patients can find the most cost-effective care.

[Also: Cardiologist says new bundled payment program 'adds another click']

"Our members wanted to make sure there is a level playing field, and that providers who are entering into these sort of payment models would have the information about who else is participating in the model and also the idea of figuring out who to compare the costs across each of these settings of care," said Jeff Coughlin, HIMSS senior director of federal and state affairs.

Across the board, HIMSS encouraged the practice of information sharing when it asked CMS to "be explicit in this Final Rule on encouraging and fostering the use of health information exchange mechanisms to ensure that the right information on the right person is available to the clinician at the right time."

HIMSS, however, said it supported provisions to ensure all related services to the bundled payment models should be included in the coding and reimbursement structure. Coughlin said there are a wide variety of new technologies out there, including population health and care coordination technology, that should be included under the same reimbursement process, not treated separately.

"If it is separate, I think it's one more thing for the provider to have to worry about to try and incorporate. Reducing the complexity for providers and simplifying things as much as possible to make it easier for them to focus on delivering better outcomes, that's what we wanted to focus on there," Coughlin said.

While HIMSS supports the proposed waivers for Medicare program requirements such as the geographic site requirement for telehealth services, HIMSS urged changes to the regulations surrounding it. They urged CMS to expand the role of telehealth services and its program requirements to allow even greater flexibility.

"Given the extraordinary advances occurring in the health IT field, CMS's 15-year old definition of the statutory term 'telecommunications system' requiring the use of 'multimedia communications equipment that includes, at a minimum, audio and video equipment permitting two-way, real-time interactive communication' is out-of-date," HIMSS said. "There is no statutory restriction prohibiting CMS from replacing its outdated reference to 'audio and video equipment permitting two-way, real-time interactive communication.'"

[Also: CMS mandates new bundled payment program]

HIMSS called for the revision of two key definitions that limit telehealth use. First, the organization said the 'store and forward' definition ignores valuable information not actually gathered during the telehealth visit like remote patient monitoring data. For instance, the information gathered by a heart rate monitor can be used by the patient and the provider in guiding treatment, but figuring how to reimburse a provider the work they do outside a telehealth visit to evaluate that information stream and related data needs to be figured into the EPM model.

Second, the current definition of two-way audio/visuals limits the telehealth interactions that can occur between clinicians and patients. It rejects e-mail, phone conversations, and other modes of 'asynchronous telecommunication', and instead depends on real-time/active audio and video interactions. There are numerous new health-related technologies that serve telehealth, and are low cost, that rely on store and forward technology or employ an active alert management structure beyond audio-visual communication. Those methods need to be included, HIMSS said.

"There's a lot of good in here related to telehealth, but I think there could be an opportunity for CMS to provide even more flexibility on telehealth issues," Coughlin said.

The FAH and its members, however, said in their lengthy official comments that their level of concern has been steadily rising due to the pace of change proposed by CMS and what they call the 'unreasonable expectations and burden' that the proposed changes in the delivery system and related payment structure put on hospitals and their staff.

"Simply put, this is too fast and too soon. We strongly believe that CMS first needs to evaluate and learn from hospitals' Comprehensive Care for Joint Replacement Model experience (a model with less than 6 months of history) and from the Bundled Payments for Care Improvement initiative Model 2 results. Establishing 'proof of concept' is a very important tool to utilize before implementing new mandatory episode payment models that could affect large numbers of Medicare beneficiaries and potentially have significant and adverse unintended consequences if not implemented in a reasonable, thoughtful and deliberate approach," FAH said.

FAH wants CMS to delay the implementation of the new models until January 1, 2018, and additionally, they asked that if the final rule is delayed beyond January 1, 2017, then CMS should provide hospitals with at least 12 months of preparation time from the date the final rule is finalized. They further requested that hospitals not be subject to downside risk for at least 12 months (as was provided in CJR) from the proposed delayed implementation timeline.

"We believe an additional 6 months is warranted given all of the other competing priorities for hospitals and the complexity of implementing these EPMs successfully."

The American Medical Association also weighed in with concerns, saying CMS did not solicit feedback prior to the release of this proposed rule from the medical specialty societies whose members will be the participating providers in these EPMs. They urge CMS to weigh very seriously their comments on the proposed rule.

Like Healthcare Finance on Facebook

"Greater benefits and fewer unintended consequences will occur if new payment models are specifically designed with input at the front end from specialty societies whose members provide the services included in the new EPMs," the AMA said.

They also stressed that physicians, not government agencies, should play the central role in redesigning care delivery under the new EPMs, saying the new EPMs fail to recognize the central and essential role of physician leadership in care redesign.

"CMS proposes to designate the hospital as the accountable entity for all services the Medicare beneficiary receives, including services delivered by physicians and post-acute care providers. A bundled payment should instead be developed so physicians have leadership roles in designing the care delivery process and ensuring that it achieves good patient outcomes without unnecessary costs. The physicians, hospital, and other providers involved in the episode can then decide together what role the hospital should play in the coordination and financing of the care, rather than this being dictated by CMS in regulations," AMA said.

Twitter: @BethJSanborn