The move by CMS to delay mandatory bundled payments for cardiac and orthopedic care was widely supported by medical associations and health systems, judging by their comments to the agency, but some went further, calling for these initiatives from the prior administration be made into voluntary programs.

CMS delayed the implementation of four new bundled payment models from June 1 to Oct. 1, and asked for additional feedback on a longer delay to Jan. 1, 2018. The Federation of American Hospitals (FAH) was among the groups supporting the even longer delay, arguing the extra time would allow hospitals to have the needed infrastructure and for the quality measures to be revised.

Even with the delay, the FAH said the models have to be voluntary, arguing CMS doesn’t have the authority under the Center for Medicare and Medicaid Innovation (CMMI) to force hospitals and providers to participate in any payment model.

“This policy mandate would be imposed on providers and suppliers without any testing; this is neither permitted nor contemplated by the language of the statute or any expression of congressional intent,” the FAH said in its official comment.

Individual health systems also called for the models to switched to voluntary. The eight-hospital Presbyterian Healthcare Services (PHS) of New Mexico said collecting data under previous bundles was “arduous” and could complicate efforts to redesign care at providers which lack the experience or infrastructure to handle these changes.

“Voluntary demonstrations—such as the Bundled Payments for Care Improvement (BPCI) Models—that allow providers to tailor their episode-of-care models to their unique patient populations—would lead to improved patient care and more accurate and efficient payments,” PHS said.

There wasn’t uniform opposition to the mandatory bundles among the commenters.

The American Hospital Association, for example, supported delaying the models’ start date to Jan. 1, 2018, but opposed moving it back any further, saying it would create a “moving target—hospitals and health systems would continue to expend resources to prepare for something that we fear would never come to fruition.”

Pennsylvania-based Geisinger Health System also supported the Jan. 1 start date. In contrast to the argument from PHS, Geisinger said voluntary models like BCPI produce limited results compared to what a broader, mandatory model could provide.

“Participants in voluntary models tend to be early adopters whose performance may be systematically different than hospitals that choose not to participate—limiting the generalizability of program results, it said, adding that a mandatory program “limits participants’ ability to ‘game the system’ by selectively referring or transferring complex patients to nonparticipating hospitals.”