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.
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