NAHC Submits Comments on the Proposed Cardiac Bundle Model
October 6, 2016 02:23 PM
On August 2, 2016, the Centers for Medicare & Medicaid Services (CMS) issued the proposed rule: Advancing Care Coordination Through Episode Payment Models (EPMs); Cardiac Rehabilitation Incentive Payment Model; and Changes to the Comprehensive Care for Joint Replacement Model (CJR). The propose rule outlines the structure for a bundled payment project for acute myocardial infarctions (AMI), coronary artery bypass graphs (CABG), and adds surgical hip/femur fracture treatments (SHFFT) to the CJR bundled initiative that went into effect April 1, 2016. (See NAHC Report, September 2, 2016.)
The National Association for Home Care & Hospice submitted the following comments expressing concerns regarding CMS’ plan to implement additional bundled episode payment models without fully evaluating the effectiveness of the CJR model.
Overall, NAHC is highly supportive of innovations in Medicare that improve access to care, enhance the quality of health care services and patient care outcomes, and institute efficiencies in Medicare spending. Medicare is one of the most valuable public programs in the country and should operate in the best interests of present and future Medicare beneficiaries. With the expected growth in Medicare spending related to the aging baby boom generation, innovative approaches to care and the financing of that care should be explored thoroughly. The proposal by the Centers for Medicare & Medicaid Services (CMS) to institute a pilot program that essentially “bundles” payments for acute myocardial infarction (AMI), coronary artery bypass graph (GABG), and surgical hip/femur fracture treatment (SHFFT) episodes, collectively referred to as episode payment models (EPMs), is a positive step in that direction. At the same time, we support CMS’s recognition that innovations be approached carefully to ensure that there are no unintended adverse consequences.
In line with such caution, NAHC recommends that CMS delay the implementation of the new EPMs until it has evaluated the impact of the Comprehensive Care for Joint Replacement (CJR) model to determine whether these new payment models will actually achieve CMS’ intended goals to improve efficiencies in care delivery and increase quality of care for Medicare beneficiaries.
Although bundle payment models may work to create efficiencies in health care delivery they can also encourage negative behaviors by the entity(s) that bears the financial risk, such as stinting on care; a delicate balance that CMS has expressed concern over in both this proposed rule and with the initiation of the CJR model. Therefore, it perplexing why CMS would go forward with plans to create and test three new episode payment models that will impact a significant number of Medicare beneficiaries and health care providers without clear evidence of the effectiveness of these models.
CMS has relied on other models and demonstrations currently and previously conducted by the Center for Innovation, such as, the Bundle Payment in Care Improvement (BPCI) model and the Medicare Acute Care Episode (ACE) demonstration to inform them on the EPMs. However, an important distinction is that participation in the other models and demonstrations is voluntary, while the proposed EPMs require mandatory participation by both the beneficiary and the entity bearing the financial risk. This difference significantly limits the comparison between the models or the ability of one model to inform the performance of other model.
CMS proposes to take remedial actions if an EPM participant or its related EPM collaborators, collaboration agents or downstream collaboration agents fails to comply with any applicable requirements or is identified as noncompliant. Monitoring is to be through HHS, including CMS and the Office of Inspector General. However, CMS does not outline how it plans to monitor providers for compliance other than through claims review for changes in utilization patterns. Meaningful claims data required for oversight of the EPMs will not be available for years after the model has been implemented. In addition, utilization patterns measure only one aspect of compliance.
CMS should delay the EPMs until such time that CMS has sufficient data from the CJR model to support whether implementing additional bundled payment models is appropriate. Lessons learned and evidence from the CJR model should inform CMS on the future construct of any EPM. Additionally, CMS should develop a robust compliance monitoring program to test on the CJR model that monitors claims data, cost reports, quality measures for all Part A and Part B providers, beneficiary complaints, and includes a schedule for medical record audits.
Realizing the CMS may choose to go forward with implementing the proposed EPMs, NAHC attached the comments submitted in response to the proposed rule for the CJR. In light of the similarity in the structure of the two models, the concerns for home health agencies for the EPM are the same as were for the CJR model.