Bundled payment cancellation by CMS draws calls for new Advanced APMs

When the previous administration at CMS finalized rules on mandatory bundled payment models for cardiac and orthopedic care late in 2016, 221 public comments were received. The cancellation of those same bundles, however, drew only 85 official comments as of Oct. 18.

CMS announced in August it would cancel two mandatory models, the Advancing Care Coordination through Episode Payment Models (EPMs) and Cardiac Rehabilitation Incentive (CRI) Payment Models, and proposed to make the Comprehensive Care for Joint Replacement (CJR) model voluntary. The move wasn’t a surprise, as both CMS Administrator Seema Verma, MPH, and then-HHS Secretary Tom Price, MD, had been critical of mandatory payment models in the past.

The comments CMS received from larger groups were largely supportive of the cancellation. Mayo Clinic cardiovascular consultants Regis Fernandes, MD, and Randal Thomas, MD agreed participation in bundled payment models should be voluntary, arguing it could adversely impact systems which take on the sickest and riskiest patients. It did encourage the agency to retain the CRI model in some voluntary form.

“Cardiac rehabilitation is underutilized, due to a number of barriers patients face,” they wrote. “Studies suggest that innovative approaches, like incentive programs, help to improve the delivery of these important services, resulting in improved patient outcomes and reduced recurrent cardiovascular events.”

Several commenters, including the American Physical Therapy Association and the American Hospital Association (AHA), mentioned concerns that providers would be unprepared for the mandatory models when taking into account other administrative burdens. On the other side of the coin, the AHA said some of their members have “already expended valuable resources” to prepare for these models, as they would have qualified for the 5 percent bonus payment under the Advanced Alternative Payment Models (AAPMs) track in the Medicare Access and CHIP Reauthorization Act (MACRA).

“We urge CMS to expeditiously pursue the creation of new, voluntary advanced APMs that would allow hospitals to not only capitalize on the work many of them already have done to prepare for such models, but also partner with clinicians to provide better quality, more efficient care,” wrote Thomas Nickels, AHA’s executive vice president.

Nickels specifically mentioned adding cardiac and surgical hip and femur fracture treatment (SHFFT) tracks to the existing Bundled Payments for Care Improvement (BCPI) program as one possibility. Comments from electronic health records giant Cerner also mentioned BCPI as an option for would-be EPM and CRI participants, except CMS cancelled the models so late that providers can no longer enroll in it or many other AAPMs.

The criticisms of the cancellation came from individual commenters and groups representing the concerns of employer and consumers health benefits. The Consumer Purchasing Alliance, for example, said a voluntary bundled payment model “may limit its ability to affect change throughout the system” and stymie efforts to transition away from fee-for-service payment.

“We are concerned that CMS is sending signals that will slow this transformation, and urge you to clarify that value-based payment and care delivery is an urgent priority,” the alliance wrote.

Individual commenters, such as North Carolina’s Robert Barnabei, MD, were the most critical. Barnabei wrote that with voluntary participation, he feared “process improvement will not remain consistent” across providers and organizations will revert to their traditional care delivery methods.

Groups which supported cancellation did emphasize their position shouldn’t be interpreted as support for sticking with fee-for-service.

“However, we do not want to give the impression that our lack of support for the (EPM) is somehow indicative of a lack of support for value-based payment,” wrote Richard Prager, MD, president of the Society of Thoracic Surgeons (STS). “In truth, STS has been at the cutting edge of improving quality of care for cardiothoracic surgery patients. Some of our concerns with the proposed (EPM) signified that the medical specialty society representing the surgeons who would be directly impacted by the proposed payment model felt we could do a better job of driving Medicare value-based payment.”