How the Cardiac Care Bundle Will Burden Hospitals

CMS's latest bundled payments program is beset by "unrealistic expectations" and needs to be modified to account for patient acuity and other factors that can skew reimbursement, says one expert.

First, some good news: Expect a rollback of the aggressive implementation timeline for the cardiac care bundled payments program announced by CMS Monday.

Now, the bad news: Preparations, including developing strong relationships with other pieces of the cardiac care continuum, need to start now.

Regardless of whether your organization is in one of the 98 randomly selected geographic regions ultimately selected for mandatory participation in the program, no one should waste the probable delay.

Medicare Proposes Bundled Payments for Cardiac Care

So says Colin Luke, a partner at the Birmingham, AL, office of Nashville-based law firm Waller. The complexity of the cardiac care bundle program surprised him, even given his experience helping systems navigate regulatory compliance matters related to CMS's bundled payment programs for total joint care and cancer care.

"The complexity was beyond what I expected and the degree to which the hospitals will bear the burden is greater than expected," says Luke.

Hospitals' administrative expenses to participate in the mandatory program will likely exceed any possible financial rewards available during the course of the proposed rule, he says. It runs through 2021. After that, CMS expects to tweak and expand the bundling program nationwide.

But first, there is a public comment period that closes at the end of September.

Administrative Hassles Eyed

Luke expects hospitals to take a view in the short term that participation in the program as detailed in a CMS fact sheet will dramatically increase their administrative burden while rewards for such investments won't be seen until far down the line.

"I doubt many [hospitals and health systems] believe in the short term that participation is going to be worth the extra expense and administrative hassles," he says.

"CMS has figured out how to make a hospital accountable for non-employed, non-contracted, non-affiliated providers that are responsible for most of the downstream and parallel care. Even without downside risk (in the first 15 months or so of the program), hospitals are exposed to unrealistic expectations."

Luke says the program lacks critical adjustments for outliers and a lack of adjustment for the complexity of the initial cardiac case, and expects a large volume of public comment to focus on that area. He expects "substantial" numbers of comments that reference "significant issues" with ambiguity around the ability to recover what he calls significant administrative costs.

"It wouldn't surprise me if [the timeline for implementation] gets rolled back because providers will need sufficient education and resources in those geographic areas to make the program manageable," he says.

More Meaningful, Less Bureaucratic

"Instead of just encouraging collaboration, [the program] needs significant mechanisms for paying for that collaboration. My general sense is that this demonstration project was not developed with sufficient provider input and the whole process could be more inclusive."

"Hospitals and physicians are generally supportive of coordinating care and working together for good of the patient, but want to do so in a more meaningful, less bureaucratic sense."

Luke says what he calls a quick rollout of these programs results from CMS's self-imposed deadline to tie 50% of Medicare payments to alternative payment models that reflect quality or value by 2018.  

Patrick Conway, acting principal deputy administrator and chief medical officer of the Centers for Medicare & Medicaid Services, told media in a conference call Monday that one of the policies in the proposal to increase cardiac rehabilitation had particular promise in helping patients recover and regain health following a cardiac episode.

Only 15% of heart attack patients currently receive rehabilitation services, Conway noted, despite the fact that participation in such programs can lower the risk of a second heart attack or death.

That's where Luke says statistics can be misleading and in this case underscore that big changes need to be made to the proposal to account for patient acuity and other outliers that may skew statistics and thus, reimbursement.

"Some are too sick to participate or have other comorbidities that affect participation that may have resulted in death before they could participate," he says.

Luke says that much of the innovation around developing symbiotic relationships among entities that have not been previously financially intertwined is already happening in the private sector, which should provide some help in preparing for the new CMS bundle.

If your organization is being proactive in this way, you should have a head start if your geographic region is ultimately one of the 98 selected.