Just as many hospitals are adjusting to the Comprehensive Care for Joint Replacement (CJR) bundled payment model, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule on the next bundled payment model – the cardiac bundle (bypass surgeries and heart attacks). Many in the industry are not surprised that bypass surgeries and heart attacks are the focus of the next bundle because, according to a recent HHS press release, in 2014 hospitalizations for heart attacks for over 200,000 beneficiaries cost Medicare over $6 billion.
So what do hospitals need to know?
- Mandatory? Yes for hospitals within the defined markets. Similar to the CJR model, the cardiac bundle would be mandatory making hospitals in 98 markets financially accountable for the cost and quality of care associated with bypass surgeries and heart attacks through 90 days post discharge.
- When does the cardiac bundle go into effect? Effective July 1, 2017 but downside risk will not go into effect until the second quarter of the second performance year (April 2018).
- How long is the proposed payment model? 5 years.
- How is CMS calculating payments? CMS proposes to set prices using historical regional data and hospital-specific data for hospitalization and related care 90 days after the patient is discharged.
- What is the financial risk to hospitals? CMS proposes a phased risk approach.
- July 2017 to March 2018: No repayment
- April 2018 to December 2018: Repayment capped at 5%
- 2019: Repayment capped at 10%
- 2020 to 2021: Repayment capped at 20%
- What are the financial gains for hospitals?
- July 2017 to December 2018: Capped at 5%
- 2019: Capped at 10%
- 2020 to 2021: Capped at 20%
- In addition to financial gains, CMS proposed allowing physicians in the bundled programs to qualify as participating in an Advanced Alternative Payment Model under MACRA, meaning those providers are exempt from the specific reporting and performance requirements under the rule.
- When are comments due? September 24, 2016.
CMS also used this proposed rule to expand CJR to include surgeries repairing hip and femur fractures.
For further detail and to access the proposed rule, go to https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-25.html.