Proposed Cardiac Care Model a Burden, Hospitals Say

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By Michael D. Williamson

July 27 — The Medicare agency shouldn't force hospitals to participate in a cardiac care pilot program on top of other mandatory demonstration programs, industry groups said July 27.

Many hospitals are already subject to the Comprehensive Care for Joint Replacement (CJR) model for hip and knee replacements, and requiring some hospitals to also participate in the Cardiac Bundled Payment Model would create a big burden, said Joanna Hiatt Kim, the American Hospital Association's vice president of payment policy.

The Centers for Medicare & Medicaid Services only started the joint replacement program in April and the agency should have given everyone more time to learn from that pilot before proposing a new one, Ivy Baer, a senior director and regulatory counsel at the Association of American Medical Colleges (AAMC), told Bloomberg BNA.

Bundled payment models are one way the CMS is trying to reduce variations in treatment costs among hospitals while improving outcomes. With bundled payments, hospitals receive one payment for an entire episode of care that spans acute and post-acute care instead of receiving separate pay for individual services under the fee-for-service schedule.

Hospitals could face a financial downside for not coordinating follow-up care for heart attack and coronary bypass surgery patients under the cardiac model. The proposed rule (CMS-5519-P; RIN:0938-AS90) outlining the cardiac model was issued July 25, and will be published Aug. 2 in the Federal Register (143 HCDR, 7/26/16). Comments on the proposal are due 60 days after publication.

Too Many Mandatory Demos?

The CJR model is mandatory for hospitals in 67 metropolitan areas randomly selected by the CMS. In the new proposed rule, the CMS specified that the Cardiac Bundled Payment Model would be mandatory for hospitals in 98 metropolitan areas the CMS randomly selects. There could be some metropolitan areas that are subject to both programs, Kim said.

When the CMS released the proposal that led to the CJR program, it listed the metro areas it selected for participation, Jessica Walradt, a senior payment reform specialist at the AAMC, told Bloomberg BNA July 27. However, the agency didn't do that when it announced the cardiac care model July 25, which is a problem because it doesn't allow facilities to prepare ahead of time, she said.

Hospitals shouldn't be forced to participate in the cardiac care model, Erin O’Malley, director of policy at America's Essential Hospitals (AEH), told Bloomberg BNA July 27. The AEH is an industry group that represents safety-net hospitals.

Another proposed CMS demonstration project, the Part B drug model, also would be mandatory for many providers, O'Malley said. Under that model, the CMS would test six approaches for paying for Part B drugs, such as cancer medications. In 2015, Medicare Part B spent $20 billion on outpatient drugs administered by physicians and hospital outpatient departments, a $9 billion increase over what was spent on the same medications in 2007.

However, there has been a great deal of resistance to the Part B model, which could cause the CMS to change course, O'Malley told Bloomberg BNA. If the CMS receives similar resistance on the cardiac care model, the agency also could delay or alter it, she said.

That being said, health-care lobbyist Martin Corry told Bloomberg BNA July 27, the feedback he has seen on the rule so far shows people aren't that upset with the model being mandatory. If hospitals, however, feel that they are being asked to do too much in the program, especially if they are already subject to the CJR model, they should tell the CMS that in formal comments, said Corry, who is with law firm Hooper, Lundy & Bookman P.C. in Washington.

Some Benefits

Others praised various parts of the proposed model.

There’s no downside risk in the first nine months of the cardiac care model, Joshua Seidman, a senior vice president at the consulting firm Avalere, told Bloomberg BNA July 27. This gives hospitals time to get used to the program, he said.

The rule would also allow physicians participating in the CJR and cardiac care bundled models to qualify for advanced alternative payment models (APMs) under the doctor payment system that the CMS proposed in April, as a result of the Medicare Access and CHIP Reauthorization Act (MACRA).

The MACRA proposal offers doctors and other clinicians a choice of aligning themselves with an advanced APM and receiving a 5 percent annual bonus or being subject to a quality performance score that could lead to reductions or increases in their Medicare reimbursement (82 HCDR, 4/28/16).

Before the CMS released the cardiac care model, it didn't allow physicians working in the CJR program to qualify for the advanced APMs, the AHA's Kim said. “We really commend” the CMS for making that change and allowing the cardiac care model to count, too, she said.

Heart Association's Take

The American Heart Association, a medical society for heart health professionals, praised the CMS for releasing the proposed cardiac care model.

“We believe the proposed Cardiac Rehabilitation Incentive Payment Model could be a significant step in the right direction to overcome this challenge by incentivizing providers to coordinate” cardiac rehabilitation (CR), which is underutilized among eligible patients, Steven Houser, the American Heart Association's president, said in a July 26 statement.

In the case of CR, the evidence for patient benefit couldn't be clearer, Houser said: CR reduces the risk of a future cardiac event, reduces hospital readmissions, and improves a patient's overall quality of life. He added, “We look forward to further reviewing the details of the proposed CR Incentive Payment Model, and we are committed to working with [the Department of Health and Human Services] in the design and testing of this new approach for cardiac rehabilitation.”

To contact the reporter on this story: Michael D. Williamson in Washington at

To contact the editor responsible for this story: Brian Broderick at

For More Information

The cardiac care proposed rule is at

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