AHA to CMS: Simplify Cardiac Bundled Payment Model, Slow Pace of Change

Oct. 3, 2016
The American Hospital Association (AHA) is urging the Centers for Medicare & Medicaid Services (CMS) to simplify the proposed cardiac bundled payment model and to only expand it when there has been time to track and process the outcomes of existing models.

The American Hospital Association (AHA) is urging the Centers for Medicare & Medicaid Services (CMS) to simplify the proposed cardiac bundled payment model and to only expand it when there has been time to track and process the outcomes of existing models.

In a letter to Andrew Slavitt, acting administrator for CMS, Thomas Nickels, executive vice president for the AHA, expressed hospital members’ support for the underlying principles of the proposed cardiac bundled payment model and efforts to transform care delivery through improved care coordination and financial accountability. However, the AHA states that the proposed rule “raised serious concerns about the agency’s pace of change, as well as its ability to accurately track and process the outcomes of its myriad increasingly complex alternative payment models."

AHA represents nearly 5,000 member hospitals, health systems and other healthcare organizations and 43,000 individual members.

AHA is urging CMS 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,” Nickels wrote.

The AHA’s comments follow the U.S. Department of Health and Human Services (HHS) announcement July 25th that the department plans to introduce mandatory bundled payment for care for heart attacks and for cardiac bypass surgery as well as extend the existing bundled payment model for hip replacements to other hip surgeries. The announcement came in the form of a formal Notice of Proposed Rulemaking (NPRM).

According the letter, AHA members are concerned that CMS is proposing to implement a cardiac bundled payment model less than four months after the comprehensive care for joint replacement (CJR) model began, and AHA also is concerned about the complexity of the proposed cardiac model.

Nickels wrote, “For example, CMS would set no fewer than 75 different target prices for different combinations of cardiac diagnoses and procedures, making it difficult for even trained clinicians to know whether the agency’s proposals are directionally correct. Because hospitals’ data and resources are limited, they will have little, if any, ability to independently verify any of CMS’s calculations. We urge the agency to proceed at a more deliberate pace and simplify the rule.”

He continued, “For example, we urge the agency to consider including only coronary artery bypass grafts (CABGs) in the cardiac model to start. As hospitals work through implementation and gain experience, the agency could then phase in the inclusion of the much more complicated acute myocardial infarction (AMI) episodes.”

And, AHA does not support CMS’s proposal to expand the CJR program to include surgical hip and femur fracture treatment episodes or to require certain CJR hospitals to also implement the cardiac bundled payment model, noting that the proposals “go too far too fast.”

“Neither CMS nor the hospital participants have had the time or the data to be able to analyze the lessons learned, successes or failures,” Nickels wrote. “We urge CMS to reconsider expanding the model only when a solid foundation of evidence, analyses and evaluations is present.”

Additionally, AHA is concerned about CMS’s proposal to implement the cardiac bundles in the same geographic areas of the CJR model. In the letter, Nickels wrote that the agency must give hospitals and health systems time to standardize care patterns and identify opportunities for care redesign, as well as adequate opportunity for testing and evaluation of bundled payment models.

“Hospitals strongly support CMS’s push for adoption of alternative payment models and are working to help ensure these complex models work for patients. However, if the agency does not, in turn, support hospitals by recognizing the significant investments of time, effort and finances that these models require, neither we nor the agency will find success,” Nickels wrote.

AHA also recommended a number of program improvements in the 40-page letter. Specifically, AHA urged CMS to incorporate a risk-adjustment methodology into the cardiac model, the existing CJR model and the surgical hip and femur fracture treatment episodes. The AHA also recommends CMS incorporate a more “robust transfer-adjustment methodology for cardiac episodes.” Additionally, AHA is asking CMS to implement smaller discount factors in the cardiac model than proposed.

AHA also urges HHS to waive the physician self-referral law and the anti-kickback statute with respect to financial arrangements formed by hospitals participating in the model.

As proposed, the rule places too much risk on providers with little opportunity for reward in the form of sharing savings, Nickels wrote, and recommended that CMS take a more balanced approach, such as delaying downside risk implementation until 15 months after the model begins and providing additional protections in the form of lower stop-loss limits for hospitals that have a low volume of episodes.

Additionally, AHA recommends CMS remove the proposed excess days in acute care measure from the AMI model measure set and adopt a flexible reporting approach to the proposed voluntary AMI mortality measure and assess all measures for the impact of socioeconomic factors and incorporate adjustments if needed.

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