The Centers for Medicare and Medicaid Services is laying the groundwork for new Medicare payment models for cardiac procedures.
Bundled payments for cardiac care may be the next of other programs in other areas seeking to use the approach.
However, CMS and other research within the industry suggests that the lack of appropriate information technology may cause problems for bundled payment approaches.
Acute care hospitals in selected regions will participate in the cardiac program, according to a rule proposed earlier this month. “All related care within 90 days of hospital discharge will be included in the episode of care,” according to the rule, which will undergo an industry comment period before being finalized.
“We believe this model will further our goals of improving the efficiency and quality of care for Medicare beneficiaries receiving care for these common clinical conditions and procedures.”
In particular, CMS is interested in understanding the readiness of physicians and suppliers to take financial responsibility for episode costs and quality not just for cardiac care but also “in potential further episode payment models” that could include maternity care, for instance.
Under the proposed rule, group practices in the Bundled Payments for Care Improvement program (Model 2) may assume financial responsibility for as many as 48 clinical conditions “for the anchor inpatient admission and up to 90 days post hospital-discharge.” For the BPCI Model 3 program, group practices and post-acute care providers such as skilled nursing homes, inpatient rehabilitation facilities, home health agencies and long-term care facilities may bare financial responsibility for as many as 48 clinical conditions extending up to 90 days following initiation of post-acute care following an in-patient hospitalization discharge.
The rule is notable in that CMS acknowledges that health information technology challenges and disconnects await providers if the proposed rule is finalized.
CMS notes that a recent survey found routine use of IT for administrative purposes in nursing homes, but less use for clinical care, and the agency acknowledges that “availability of health IT that can be used in beneficiary management across care settings may pose a significant barrier to the readiness of non-hospital providers and suppliers to assume financial responsibility for episodes in potential future episode payment models.”
For instance, a recent extension of Medicaid 90/10 funding of states will enable post-acute care providers to engage in projects focused on infrastructure development, “but will not address the cost of health IT among post-acute care providers,” the proposed rule states.
Consequently, CMS will explore incentives for post-acute care providers and suppliers to make investments in certified health IT infrastructure. The agency asks for comment on sufficient incentives or bonuses to enhance IT upgrades and adoption, and ways that episode payment models could encourage use of IT and health information exchange, as well as support care coordination and improved patient outcomes.
To further support use of IT, CMS proposes adopting waivers of the telehealth and originating site and geographic site requirements to permit in-home telehealth visits, along with a general waiver to allow post-discharge nursing visits in the home. Telehealth visits will be paid using unique HCPCS codes.
A recent survey conducted by McKesson found that only half of payers and 40 percent of providers are ready to implement bundled payments. Further, the research found that only 25 percent of providers currently have the tools in place to automate this model.
“We see bundled payments as a model that’s growing and expected to grow faster, but other models are also growing,” says Andrei Gonzales, the director of value based reimbursement initiatives at McKesson Health Solutions. “All these models work very well together for different things, in different places and different regions. You need to recognize the size and depth of these different characteristics.”
“Hospitals say they aren’t effective at tying their payments to measurements,” Gonzales says. “There’s also a struggle to engage patients and get them locked into pathways they should be following to manage costs effectively.”
Meanwhile, both hospitals and payers project bundled payments will top 17 percent of medical payments in five years, with health plans projecting a 6 percent growth over that time.
The proposed CMS rule for bundled payment for cardiac care is available here.
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