Cardiac bundles to be canceled by CMS

A rule title posted to the Federal Register on Aug. 10 indicates CMS will cancel two mandatory bundled payment programs, the Advancing Care Coordination through Episode Payment Models (EPMs) and Cardiac Rehabilitation Incentive (CRI) Payment Models, which were set to start in 2018.

These same bundles have already been delayed twice since HHS Secretary Tom Price, MD, and CMS Administrator Seema Verma, MPH, took the reins at the agencies. Both have been critical of making bundled payments mandatory, with Verma saying in her confirmation hearing that new payment models should be expanded more gradually. Price, an orthopedic surgeon, had been the lead author on a letter to CMS in 2016 criticizing the mandatory cardiac bundles and the expansion of a joint replacement bundle, saying the moves would lead to providers consolidating and turning away Medicare beneficiaries.

"Medicare providers and their patients are blindly being forced into high-risk government-dictated reforms with unknown impacts,” he wrote. “Any true medical experiment requires patient consent. However, patients residing in an affected geographical area will have no choice about their participation.”

Some of Price’s concerns have been countered by research. An Aug. 2016 analysis by Avalere said that 85 percent of the hospitals required to participate in the cardiac bundles wouldn’t experience gains or losses greater than $500,000 per year. Institutions with spending already far above the regional average would face the heaviest losses.

The elimination of the cardiac bundles would remove a path for practices to qualify for the 5 percent bonus in 2019 under the Advanced Alternative Payment Models (AAPMs) track introduced by the Medicare Access and CHIP Reauthorization Act (MACRA).

Opinion within the industry has been mixed. Several groups, like the Federation of American Hospitals, have echoed Price’s argument that CMS and the Center for Medicare and Medicaid Innovation (CMMI) doesn’t have the authority to force providers to participate in any payment model. Other stakeholders, like Pennsylvania’s Geisinger Health System, supported delaying the bundles until 2018, but said making them voluntary would limit the “generalizability of program results.”

HHS and CMS didn’t respond to a request from Cardiovascular Business for clarification on the scope of the changes to the payment models. The American College of Cardiology declined to comment “until the final rule has come out for us to review.”