CMS proposes bundled payments for AMI, CABG



The Centers for Medicare & Medicaid Services is proposing new bundled payment models for acute myocardial infarction and coronary artery bypass grafting, and a separate payment to incentivize the use of cardiac rehabilitation.

As part of the proposal, CMS also is developing a pathway that would allow the bundle to be recognized as an advanced alternative payment model under the Medicare Access and CHIP Reauthorization Act and qualify the physicians and clinicians being paid through the model for the 5% incentive payment.

Dr. Patrick Conway

Dr. Patrick Conway

The proposed bundled payment model would place patient care accountability for 90 days after discharge on the hospital where acute myocardial infarction care or coronary artery bypass grafting occurred. Beginning July 1, 2017, hospitals in 98 randomly selected metropolitan statistical areas would be placed under this model and monitored for a 5-year period to test whether the model leads to improved outcomes and generates cost savings.

The proposed rule can be seen here and an advanced notice is expected to be published on the Federal Register website on July 26. CMS will be accepting comments on the proposal for 60 days following official publication in the Federal Register.

“In 2014, more than 200,000 Medicare beneficiaries were hospitalized for heart attack treatment or underwent bypass surgery, costing Medicare over $6 billion. But the cost of treating patients varied by 50% across hospitals, and the share of patients readmitted to the hospitals within 30 days varied by more than 50%. And patient experience also varies,” CMS Acting Principal Deputy Administrator and Chief Medical Officer Patrick Conway, MD, said during a July 25 press teleconference introducing the proposal. “In some cases, hospitals, doctors, and rehabilitation facilities work together to support a patient from heart attack or surgery all the way through recovery. But in other cases, coordination breaks down, especially when a patient leaves the hospital. By structuring a payment around a patient’s total experience of care, bundled payments support better care coordination and ultimately better outcomes for patients.”

The hospital would be paid a fixed target price for each care episode, with hospitals delivering higher-quality care receiving a higher target price. The hospital would either keep the savings achieved or, if the costs exceeded the target pricing, have to repay Medicare the difference.

Target prices will be based on historical cost data beginning with hospitalization and extending out 90 days following discharge and adjusted based on the complexity of treatment required. For the 18 months of the program (July 1, 2017, through Dec. 31, 2018) target prices would be based on a blend of two-thirds participant-specific data and one-third regional data. In the third performance year (2019), the mix would move to one-third participant data and two-thirds regional data. Beginning in 2020, only regional data would be used to set target prices.

For heart attacks, the following quality measures are being proposed: Hospital 30-day, all-cause, risk-standardized mortality following acute myocardial infarction hospitalization; excess days in acute care after hospitalization for acute myocardial infarction; Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey scores; and voluntary hybrid hospital 30-day, all-cause, risk-standardized mortality eMeasure data submission.

For bypass surgery, the quality measures will be the hospital 30-day all-cause, risk-standardized mortality rate following coronary artery bypass graft; and HCAHPS survey scores.

“CMS’s evaluation ... will examine quality during the episode period, after the episode period ends, and for longer durations such as 1-year mortality rates,” the agency said in a fact sheet describing the proposal. “CMS will examine outcomes and patient experience measures such as mortality, readmissions, complications, and other clinically relevant outcomes.”

Separately, the agency is proposing to test a cardiac rehabilitation incentive payment. The two-part cardiac rehabilitation incentive payment would be paid retrospectively based on the total cardiac rehabilitation use of beneficiaries attributable to participant hospitals.

“Currently, only 15% of heart attack patients receive cardiac rehabilitation, even though completing a rehabilitation program can lower the risk of the second heart attack or death,” Dr. Conway said. “Patients who receive cardiac rehabilitation are assigned a team of health care professionals such as cardiologists, dietitians, and physical therapists who help the patient to recover and regain cardiovascular fitness.”

The initial payment would be $25 per cardiac rehabilitation service for each of the first 11 services paid for by Medicare during the 90-day care period for a heart attack or bypass surgery. After 11 services, the payment would increase to $175 during the care period.

The number of sessions would be limited to two 1-hour sessions per day up to 36 sessions over up to 36 weeks, with the option for an additional 36 sessions over an extended period if approved by the local Medicare contractor. Intensive cardiac rehabilitation program sessions would be limited to 72 1-hour sessions, up to six sessions per day, over 18 weeks.


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