CMS gets busy: Adds payment plans for hearts and hips; plans new ACO track

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Medicare's new policies are meant to improve cardiac and orthopedic care, and also create an accountable care organization track for small practices.

The Centers for Medicare & Medicaid Services launched three new policies Tuesday that continue the push toward value-based care, rewarding hospitals that work with physicians and other providers to avoid complications, prevent readmissions and speed recovery.

The newly finalized policies are meant to improve cardiac and orthopedic care, and also create an accountable care organization (ACO) track for small practices, the CMS announced.

The cardiac care policies will create three new payment models for clinicians and hospitals that treat patients for heart attacks, heart surgery to bypass blocked coronary arteries, or cardiac rehabilitation following a heart attack or heart surgery.

Medicare spent more than $6 billion in 2014 for care provided to 200,000 Medicare patients who were hospitalized for heart attack treatment or underwent bypass surgery. The cost of their care, however, varied by 50% across hospitals and the share of patients readmitted to the hospital within 30 days also varied by 50%, federal officials said in an announcement.

The new payment model for orthopedic care is for clinicians and hospitals that provide care to patients who receive surgery after a hip fracture, other than hip replacement. The CMS also announced that it is finalizing updates to the Comprehensive Care for Joint Replacement Model, which began earlier this year.

The new Medicare ACO Track 1+ Model aims to encourage small practices to participate in the program by offering a track that has more limited downside risk than other tracks in the Medicare Shared Savings Program.

The new five-year models provide clinicians with other ways to qualify for a 5% incentive payment through the Advanced Alternative Payment Model (APM) path under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) and the Quality Payment Program.

For the new cardiac and orthopedic payment models, clinicians may potentially earn the incentive payment as early as 2018 if they collaborate with participating hospitals that choose the Advanced APM path. Incentive payments under the Comprehensive Care for Joint Replacement model may be available as early as 2017. And the new ACO track model could provide incentive payments beginning in 2018.

Models aim to improve coordinated care

“These models give providers and hospitals the tools they need to provide the kind of high-quality patient-centered care we all want for our own families, while also driving down costs for the nation,” said Health and Human Services Secretary Sylvia M. Burwell in the statement.

The new bundled payment models are meant to improve care coordination and quality by reducing unnecessary variation in care, improving patient results, and reducing preventable readmissions, HHS said.  

“As a practicing doctor, I know the importance of hospitals, doctors, nurses and others working together to support a patient from heart attack or surgery all the way through recovery,” Patrick Conway, M.D., CMS acting principal deputy administrator, said in the announcement. “These bundled payment models support coordinated care and can reward clinicians through the Quality Payment Program.”

The new policies will hold hospitals accountable too. If a Medicare patient is admitted for care for a heart attack, bypass surgery, or a hip or femur procedure, hospitals will be accountable for the quality and cost of care the patient receives during the inpatient stay and 90 days after discharge.

The cardiac models will apply to hospitals located in 98 metro areas. The surgical hip fracture treatment model applies to hospitals in 67 metro areas, which are the same metro areas currently included in the Comprehensive Care for Joint Replacement Model.

The HHS said the cardiac rehab incentive will test the impact of providing payment to hospitals to incentivize referral and coordination of cardiac rehabilitation following discharge from the hospital for a heart attack or bypass surgery. The model will include hospitals in 45 geographic areas that weren’t selected for the cardiac care bundled payment models and 45 geographic areas that were.

New plans receive lukewarm reaction

There were mixed reactions within the industry to the announcement. Tom Nickels, executive vice president of the American Hospital Association, said that while the organization was pleased with Medicare’s flexibility on risk adjustment and MACRA participation, “we remain very concerned about several key issues, particularly the pace of change.”

The bundled payment model for cardiac care is the second mandatory demonstration project the agency has finalized in just the past 15 months, he noted. “This is too much, too soon. 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.”

Nickels said hospitals shouldn’t be forced to participate in complicated new programs until the federal government proves they will benefit patients. He urged that the new bundled payment programs be voluntary.

Officials with the National Association of ACOs (NAACOS) said they were also disappointed with the agency’s aggressive bundled payment expansion. “CMS’ approach to the overlap of ACOs and bundled payments undermines ACOs’ ability to demonstrate and achieve savings through care redesign since ACO beneficiaries in approximately 90% of ACOs are not automatically excluded from bundled payment programs. CMS’ policy on the overlap of MSSP ACOs and bundled payment programs threatens the ACO model,” said NAACOS CEO and President Clif Gaus in an emailed statement.

But Andrew W. Gurman, M.D., president of the American Medical Association, said in a statement that the group was pleased that the CMS has expanded alternative payment models: "We hope that CMS will continue to expand the list of advanced APMs in the future so new delivery and payment arrangements can be supported and promoted—a win for physicians and patients alike.”