Post–Acute Care Takes Center Stage in CMS (Centers for Medicare and Medicaid Services) Plan to Expand Use of Bundled Payments for Heart Attack
Understanding what happens to patients after they leave the hospital after a heart attack is going to be essential for hospitals participating in the Centers for Medicare and Medicaid (CMS) new bundled payment plan, which could go into effect as early as July 2017.
The proposed plan would require hospitals in 98 randomly selected metropolitan areas across the country to receive bundled payments for acute myocardial infarction. The participating hospitals would receive financial incentives to boost patient enrollment and completion of cardiac rehabilitation. Cardiologists participating in this new payment model could qualify for value-based care incentives laid out in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
The proposal is part of the agency’s effort to shift 50% of the payments currently made through Medicare into alternative payment models by 2018, according to CMS. Approximately 30% of Medicare payments are already made through such value-based payment programs.
Both the American Heart Association and the American College of Cardiology were still reviewing and commenting on the details of the CMS proposal at press time, but in statements they expressed support for the overall CMS shift toward value-based care.
“As an organization dedicated to reducing disability and death from cardiovascular diseases, we believe that the movement toward value-based payment models may be a way to incentivize high-quality, evidence-based care for patients,” wrote American Heart Association President Steven Houser, PhD, FAHA, in a statement.
But Richard Chazal, MD, president of the American College of Cardiology, acknowledged the challenges ahead for clinicians adapting to the new payment model. He said he was optimistic CMS would listen and incorporate feedback on the proposal.
“While we support the concept, it is important that bundled care models be carried out in such a way that clinicians are given the time and tools to truly impact patient care in the best ways possible,” Chazal wrote.
As one of the cadre of hospitals around the country participating in CMS’s voluntary Bundled Payment for Care Improvement program, Loyola University Health System (loyolamedicine.org) is ahead of the curve on adapting to this new model of payment for heart attacks.
Loyola’s parent organization Trinity Health decided to have all its hospitals participate in the pilot project, which began in 2015, according to Chad Whelan, MD, chief medical officer at Loyola Medical Center in Maywood, IL. Loyola chose to focus on bundled payments for cardiovascular care and orthopedics, he said. In the pilot program, CMS averages 3 years of historical data on 90 days of Medicare payments to the hospital for that condition as a benchmark. Then CMS asks the hospital to reduce care costs by 2% going forward as a target.
“If you can lower [costs below the target], you get to keep the savings,” he explained. “Anything Medicare is billed above the target you actually have to pay back to Medicare.”
Loyola has not developed specific care plans for myocardial infarction or its other bundles. Instead, it is focusing on improving post–acute care for patients, which is a key driver of care costs, Whelan said. So, the hospital has worked to build relationships with skilled nursing facilities and home health agencies to better coordinate post–acute care.
“For acute myocardial infarction, the big lever is going to be working on reducing readmissions, which we’ve already been doing because of [CMS’s] readmission penalty program.”
So far, Loyola has seen costs decrease across its bundles, Whelan said. But there have been some start-up costs associated with the program. For example, adding full-time healthcare navigators, occupational therapists, or nurses to help coordinate patient care.
“We’re optimistic based on our trends that [costs] will continue to drop,” he said.
Whelan advised hospitals to prepare for the CMS’s mandatory bundle program for acute myocardial infarction by beginning to analyze in-house data on costs for 90 days of post–heart attack care.
“The biggest thing is to start looking now to understand what your data are probably going to show you,” he said. “You won’t have all the Medicare data, but you can at least start looking at your own practice patterns.”
Getting a head start on building partnerships with post–acute care providers and working on reducing readmissions could also help, he said.
“There’s no reason to wait [to start building partnerships],” Whelan said. “With the readmissions work, if you are already doing it you’ll want to double down on it.”
He also urged organizations to get acquainted with the rules of the mandatory program as soon as they are available. He explained that they are likely to be different from the rules of the voluntary program.
One of the big changes in the mandatory program is that it will incentivize cardiac rehabilitation. Despite strong evidence that cardiac rehabilitation reduces the risk of a recurrence of a cardiovascular event, only 1 in 5 eligible patients ever participate, according to the American Heart Association.
“In the case of cardiac rehabilitation, the evidence for patient benefit could not be clearer: [cardiac rehabilitation] reduces the risk of a future cardiac event, reduces hospital readmissions, and improves a patient’s overall quality of life,” wrote Houser. “Unfortunately, we also know that [cardiac rehabilitation] remains greatly underutilized among eligible patients.”
“There are many reasons patients don’t participate in cardiac rehab,” said Randal J. Thomas, MD, MS, a cardiologist at the Mayo Clinic in Rochester, Minnesota, and past president of the Association of Cardiovascular and Pulmonary Rehabilitation. Patients may not be able to get time off from work or be able to travel to cardiac rehabilitation centers. They may not understand how it can help them. They may lack insurance or be unable to afford the copays. Health systems also may have limited slots or offer rehabilitation at inconvenient times, such as during the business day.
“Most of the time, the reasons are correctable,” Thomas said.
For example, he said that facilities can establish automatic systems for referrals that don’t rely solely on physicians, or they can offer sessions before or after work hours. Some programs are exploring ways for patients to complete rehabilitation at home or at health clubs, which is not currently covered by Medicare, he noted.
The CMS proposal offers incentives to hospitals to boost participation in center-based cardiac rehabilitation after a heart attack or bypass surgery. Facilities would receive $25 per cardiac rehabilitation service completed by patients for the first 11 sessions, and after that payment would increase to $175 per service up to the number of sessions allowed by Medicare.
The incentive plan is a “significant step in the right direction to overcome this challenge [of low participation] by incentivizing providers to coordinate [cardiac rehabilitation] and ensuring that eligible patients have access to, participate in and adhere to evidence-based [cardiac rehabilitation] treatment plans,” Houser wrote.
There is evidence that incentive programs can boost participation, said Thomas. But cardiac rehabilitation programs will have to expand their capacity to meet the demand, he said. He and his colleagues have shown that even if existing rehabilitation programs modestly expanded capacity, they would still only have half the capacity needed to serve all eligible cardiac patients.
“Cardiac rehabilitation programs are going to have to step up, too,” Thomas said.
Still, Thomas was optimistic that the inclusion of incentives for cardiac rehabilitation in CMS’s proposed cardiac bundles could boost the program’s success.
“It will be a big part of helping bundled care payment plans work more efficiently and cost effectively, but also to help patients have better outcomes,” he said. n
Circulation is available at http://circ.ahajournals.org.
- © 2016 American Heart Association, Inc.