Stepping Away from Fee for Service: CMS Proposes Bundling Payments for CAD Care

A new reimbursement model for cardiac care delivery could launch as early as July 1, 2017—giving cardiologists less than a year to prepare to practice in an environment with more risks and different opportunities. Get engaged now, say the experts.  

For decades, U.S. healthcare providers have been paid based mostly on the volume of services they delivered. Over the past few years, and particularly since the Medicare Access & CHIP Reauthorization Act was passed in 2015, cardiologists have heard rumblings about the end of fee-for-service and the beginning of value-based reimbursement. On July 25, the Centers for Medicare & Medicaid Services (CMS) unveiled a proposal to bundle payments for hospitals that treat Medicare patients after a myocardial infarction or coronary bypass surgery. Now, with details available about how a bundled payment model might be applied in cardiac care, physicians and hospital administrators are looking for best practices they can put in place now. Ginger Biesbrock, PA-C, MPAS, MPH, AAC, and Anne Beekman, RN, vice presidents at MedAxiom, talked with Cardiovascular Business about getting ready for bundling.

Nearly 4,000 individuals and organizations submitted comments about the proposed rule for MACRA. Now the cardiovascular community will be responding to a proposed rule for bundled payments. Amidst so much uncertainty, what do you know?

Beekman: The only thing we know for certain is that we will paid differently and measured differently on outcomes to patients. What CMS has been clear on is that a large percentage of reimbursement will be derived from alternate payment models over the next few years. That’s what we know: It will be about value and not about volume.

In your view, what is CMS aiming to accomplish by bundling payments?

Biesbrock: CMS has said that it created the bundled payment initiative, first, to foster and incentivize coordinated, efficient and high-quality care. The concept is that financial gains will be related to more cost-effective and better quality care. Second is requiring collaboration across hospitals, physicians and other providers—something we haven’t done well in the past. Instead of just taking care of the patient in the single episode in front of us, bundling is designed to encourage thinking about the global aspects of care, including everyone who is contributing. We’re going to have to work together in a way we’ve never been asked to before. Third, bundling asks us to streamline the care continuum to improve patient experience. Fourth, bundling will require us to form new partnerships among care providers and organize ourselves around certain patient populations, procedures or diseases. The fifth objective is to foster innovation around care delivery.

CMS’s first significant forays into bundling were voluntary and focused on orthopedic care. What can the cardiology community learn from the efforts to bundle reimbursement for knee and hip joint replacement?

Biesbrock: CMS tasked the Health Care Payment Learning & Action Network (LAN) with developing recommendations for bundling payments in three areas: first, joint replacement; then, cardiac care; and last, maternity care. There’s a lot we can learn from the orthopedic community’s experience with bundling (see sidebar), which until April of 2016 was wholly voluntary but now is mandatory for 37 percent of organizations that provide hip and knee replacement services.

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Do you expect that third-party payers will follow Medicare’s lead on bundling?

Beekman: Not only will they follow, but we expect them to lead it, especially with hospital systems that have integrated healthcare plans. We’re starting to see them work through the bundled payment questions. They’re looking at appropriate costs for a pacemaker or a CABG and negotiating contracts within their own systems.

What are the implications of bundling for the healthcare workforce?

Beekman: We’re starting to see innovators getting education they need to talk about why healthcare is expensive and how they can participate in removing waste that doesn’t add value and improve patients’ health. That information is critical if you are helping manage populations of patients in a cost-effective way at the best quality.

The biggest challenge of the new payment models is how we define cost. Every system does cost accounting a little bit differently, so it makes it hard to understand what direction we’re moving in and how we’re comparing. The successful systems will be the ones that reduce waste and eliminate duplication, such as two people gathering the same information to feed it into disparate systems. Fixing that will free up resources for higher-functioning work or unique work, instead of redundant work, and it will take away some of clinician’s pain points. There also may be a need for a liaison role between payers and practitioners—to provide connectivity between the two roles so that they can understand what best practice looks like in the spirit of quality and value.

How worried should cardiovascular professionals be about the forthcoming changes?

Biesbrock: The most important take-away for everyone is to get engaged now. We can learn from those who came before us. When the comprehensive joint care bundle was originally proposed, there were concerns and the bundle was adjusted based on the orthopedic community’s feedback. So, while the cardiac bundle is in the proposal stage, we need to voice our concerns.

At the end of day, I think it’s wise to view bundling as an incentive, finally, to come together as healthcare providers to take better care of our patients. If we do that, we will be positively incentivized to do that. Time will tell how realistic it all is.

Beekman: It’s time for cardiology to be optimistic and lead the process. The things addressed in the cardiac bundle proposal are those that we’ve long recognized as pitfalls in the care continuum, such as redundancy in testing and poor handoffs of information among providers. This is a good chance to help expand the team—partner with payers, other providers and systems to streamline work—and finally take advantage of the investments we’ve made in technology and best practice standards. Bundling could help us elevate care and reduce the resource burden in healthcare.

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What steps should cardiovascular providers be taking now to prepare?

Beekman: No matter what happens with MACRA, it would be smart for everyone to look at their data. Understand your quality, your cost, and the level of standardization and best practice adoption you’ve done. Focus on where you can have the greatest impact. The orthopedic community saw post-acute care as an opportunity; in PCI, the point of entry helps identify high-cost patients and could be useful in determining where and how you can have an impact.

It’s also going to become really important to have a means for working with payers. It will be helpful to have the ability to work outside of your own practice and system, not just networking for referrals but for practice standardization. Everyone needs a means of tracking these activities outside of their scope of referrals. Look at how you can create a dashboard or metric to understand how the work you’re doing is impacting the value and quality that you’re offering to the community.

Biesbrock: If you work on all of these things right now, you’ll have a structure for success in place.

Beekman: And you’ll be providing streamlined, efficient, high-quality, low-cost care. Instead of having MACRA and bundles drive it, because we’re afraid of it or we don’t understand it, we can look at it from the practical side. Why not work on it now? Plus, it’s the right thing to do.