Cardiac Bundles — What Are the Implications?

Throughout my travels around the country and talking to cardiac programs, one of the topics we invariably turn to is the newly proposed CMS bundles. We stand on the precipice of what would be one of the most significant changes for the financial management of the acute myocardial infarction (AMI) patient. In the finalized EPM (episode payment model), CMS bundling of an index admission percutaneous coronary intervention (PCI) (DRGs 246-251) for AMI will severely challenge many hospitals to deliver a total episode of care (90 days) at a fixed price. However audacious the concept of a 90-day bundle may seem to some, a bundled episode of care may well be the answer for some systems looking to be more competitive in the current healthcare landscape. In my interview with Ryan Graver, President of MedAxiom Ventures, we discuss some of the challenges and opportunities that will be facing many cardiac programs, but also look to the future, and how embracing and possibly expanding the mandatory bundled concept could be well worth considering.                                        

- Gary Clifton, Vice President, Terumo Business Edge

1. With the final rule released and a new administration coming into office, one of the most frequent questions I am asked is “what is the likelihood that cardiac bundles from CMS would not move forward under the new administration?”

Well, Gary, that seems to be the million-dollar question as we begin 2017. We are beginning 2017 with perhaps a greater degree of uncertainty than any other period in recent memory; major policies have not been finalized and the future of government efforts are additionally unclear due to the results of presidential election, and the appointments of Dr. Tom Price and Seema Verma to lead the Department of Health and Human Services (HHS) and Centers for Medicare and Medicaid (CMS), respectively. In addition to uncertainty related to mandatory cardiovascular (CV) bundles or EPM, there are questions as to whether or not the Affordable Care Act (ACA) will be repealed or reformed, whether CMS will take a dramatic turn (or not) in regards to its current trajectory toward Alternative Payment Models (APM), and whether the 2017 Medicare Access and CHIP Reauthorization Act (MACRA), Decision Support/Appropriate Use Criteria (AUC), and Site Neutrality will continue as currently planned, be modified, or halted altogether.

What we do know is that healthcare spending in the United States grew 5.8 percent in 2015, hitting a record high of $3.2 trillion, according to estimates from CMS¹, and that without further intervention, the Medicare Trust will run out of money in the near future, thus necessitating action from the new administration to address unsustainable healthcare costs. 

While we know that Dr. Tom Price has been outspoken about rushing the implementation of new payment models, and the unknown impact to patients and their quality of care, in the middle of last year, the Comprehensive Care for Joint Replacement (CCJR) went forward, affecting more than 800 hospitals nationally. Again, with total government costs in consideration, one must look back to a November 2013 publication² by the Congressional Budget Office (CBO) to appreciate where we are headed. In this  article, the CBO estimates that the first alternative — bundling payments only for inpatient care — would reduce Medicare spending by $17 billion through 2023. The second alternative — bundling payments for inpatient and post-acute care — would produce larger savings: $47 billion through 2023. There certainly is the possibility that mandatory CV bundles may be impacted, they may be delayed, they may be made optional, and we may see changes such as the removal of AMI and a shift in focus toward only procedural bundles for PCI and coronary artery bypass graft surgery (CABG).

Furthermore, it would appear highly likely that Dr. Price will be approved as HHS secretary, as well as Seema Verma as CMS Administrator. With the Republican majority in the Senate, some estimate this could occur as soon as February 1st. Since the recently announced bundled payment program does not require legislative approval, in theory, Dr. Price could undo the program on his first day.

However, I personally believe the economics would indicate that we will see some form of episode-based payments moving forward. The new administration may seek to delay and refine the focus of these new payment models, but the need to address rising costs while improving quality should continue to drive us toward greater alignment of incentives including providers, payers, and even patients.  

2. What do you see as the biggest risk for hospitals who are not prepared for a CMS bundle?

Fundamentally, we are asking providers to manage care that traditionally has been outside their scope or influence. My impression is that most organizations have little or no sense of what percentage of 90-day episode costs are associated with post-acute care, or the true “costs” (not revenue) associated with the inpatient and physician practice portion of care for that matter, and the greatest risk is that organizations will take a wait-and-see attitude, which will put them into a reactive posture rather than a proactive stance where intentional programs and decisions can be put into place to affect care.  Our experience has found that engaging physicians and post-acute providers to agree on and redesign care processes takes time, often months, and organizations who wait will find themselves scrambling to catch up to market competitors who have lower costs. 

MedAxiom has analyzed 568,481 Medicare cardiac episodes between 2013-2015 to educate and provide detailed analysis to our members around their costs and opportunities to successfully navigate the proposed CV bundles. Again, the greatest risk is assuming that a one-size-fits-all approach will work for all episodes; for example, AMI post-acute care costs make up 40% of the total bundle, while CABG is approximately 20% and PCIs for AMI is only 16%. Thus, the focus and strategies for CABG and PCI should look very different than how providers should be organizing to manage AMI bundles and again, post-acute care is often received in skilled nursing facilities or through home health agencies, which are outside of the traditional provider’s area of focus. 

3. Where is the greatest financial exposure?

For decades, we have refined our delivery of care centered around a fee-for-service model, where volumes drove our financial performance. Providers must now understand how they are being paid relative to an episode and how to optimize performance under this new model. For example, which patients represent the greatest risk to consume greater amounts of care: is that in readmissions, post-acute, and even under what cases does the index or anchor admission drive the cost of the bundle?

Figure 1 is an analysis of the distribution of healthcare costs associated with the DRGs identified under the proposed mandatory CV bundle rule.

Not only does the distribution of costs vary significantly by condition, but the costs under these new models vary significantly by facility and will vary by patient. Table 1 shows the mean 90-day episode costs and the standard deviation, showing that there are huge outliers. Note that AMI standard deviation is larger than the AMI mean costs, which may not be surprising for a condition-focused DRG where patient conditions and comorbidities may vary significantly more than PCI and CABG, which are procedural-focused episodes. 

4. If the index admission is a PCI, where is the greatest amount of cost incurred, and how could this be mitigated?

You are absolutely correct that the index admission for PCIs represents the largest cost driver of the 90-day episode. Table 2 is a summary of the breakdown in costs across the national sample analyzed by MedAxiom Ventures.
With the index admission or procedure for PCIs representing 64% of the total episode costs of care, readmissions also represent 14% of these costs. Thus, strategies to manage the costs within the procedure while also reducing the risk of readmission should lead providers’ efforts to succeed in a 90-day bundle. 

As bundled reimbursement models progress, either through CMS or commercial payers, our anticipation is that the overall payment for the episode will reduce both, as providers decrease costs and as Medicare ratchets down their payments. Thus, the index admission will represent both the greatest risk and the greatest opportunity for providers to optimize their bundled performance specific to this procedure. 

5. You are familiar with the Medicare data on AMIs treated by PCI. ­Can you share your insights? 

Focusing on the inpatient PCIs that would be subject to the bundled payment, we see significant variation in costs, length of stay (LOS), and readmissions, which should give us some indication as to why CMS is focused on this procedure. For example, under the 224,000 episodes we analyzed, the index admission LOS was 3.7150 days, the charges for the index admission were $85,203, and the mean payment was $17,259. In a separate analysis of provider cost reports, we utilized the Medicare rate setting file to compare hospital-reported costs. The mean cost per case for the same DRGs was $17,044.86, indicating that hospitals are just breaking even on these procedures. In the simplest terms, as CMS reduces payments by 3% under the final rule, a slight positive average margin becomes negative, and by adding in the risk of post-acute care costs, providers are now facing a significant financial exposure.

Understanding your costs to deliver care, as well your ability to impact post discharge care such as readmissions and post-acute settings, will be critical to success. 

6. Do you see bundled payments expanding outside of Medicare?

Bundles certainly represent opportunity, and we have already begun to see commercial bundled contracts in many different conditions and procedures across the United States. In fact, my hospital service line developed a bundled payment with Blue Cross Blue Shield in 2005 that is still in place today. Programs that have both optimized their costs to deliver care and have developed predictable clinical approaches that have led to high quality should be evaluating commercial bundles as a strategy to prepare for larger, episode-based payment models. It is also important to note that episode-based measurement is also part of how providers will be measured under the Merit-Based Incentive Payment System (MIPS) program, which is part of MACRA, going into effect this month; thus, all providers must begin to understand and manage their episode costs if they want to be successful moving forward. 

7. Does the bundle qualify as an APM (alternate payment model)? Can you explain?

With BPCI, next-generation ACOs and Shared Savings, there are many different kinds of APMs, and CMS does anticipate that there will be overlap. Furthermore, CMS has stated they plan to expand the number of APM choices, as evidenced by the December announcement that an ACO Track 1+ will be added for 2018, as well as a yet-to-be-defined “voluntary bundled payment model”.  

CMS will exclude at a patient level from EPMs not only those beneficiaries prospectively assigned to the next-generation ACO and the comprehensive ESRD care models which also share in downside risk with CMS, but also those beneficiaries prospectively assigned to Track 3 Shared Savings Program ACOs. Understanding the overlap and exclusions rules that now apply at a patient level will be of significant importance. It also highlights the need for programs to not just adopt changes for specific patients, but rather to adopt clinical pathways and programs that will optimize care for all patients treated. 

This is also a frequent question, as providers are trying to determine whether if they were selected to participate, this will also qualify them for the APM bonus payment. It is important to understand that only qualifying APMs are eligible for APM bonus payments. Providers who are participating in another Medicare Alternative Payment Model — such as an Accountable Care Organization (ACO), patient-centered medical homes, or bundled payment model — are not necessarily eligible for APM incentive payments unless their program qualifies as an Advanced Alternative Payment Model under CMS rules. Participation in a non-qualifying Alternative Payment Model may score points on the MIPS score, and may qualify providers at a future date.

The following models are considered advanced APMs for the 2017 performance year:

• Comprehensive End Stage Renal Disease Care Model, Large Dialysis Organization and non-LDO two-sided risk arrangements
• CPC+
• Medicare Shared Savings Program ACO, Tracks 2 and 3
• Next-generation ACO
• Oncology Care Model, two-sided risk arrangement

CMS will add the following models as advanced APMs in 2018:

• Medicare ACO Track 1+
• New voluntary bundled payment model
• Comprehensive Care for Joint Replacement Payment Model, Certified EHR Technology track
• Advancing Care Coordination through Episode Payment Models Track 1, CEHRT track

CMS will update this list annually to add new payment models that qualify to be an Advanced APM. CMS will continue to modify models in coming years to help them qualify as Advanced APMs. Starting in performance year 2019, clinicians using APMs developed by non-Medicare payers, such as private insurers or state Medicaid programs, could start to qualify for APM bonus payments. Stakeholders can also suggest other models to the Physician-Focused Payment Technical Advisory Committee to review and assess.

8. Last’s month’s article by Dr. Bieniarz³ alluded to cost savings through care pathway improvements. Can this have a positive impact on bundled payment programs?

Absolutely. The literature has clearly established the benefits of transradial access on clinical areas such as the reduction of bleeding events, which can impact readmissions and even mortality, but the concept of deploying a care pathway that improves a provider’s costs to deliver is ideally how programs will begin to prepare for bundled payment success. First, your organization should understand its costs and it is important that the concept of costs needs to expand. MedAxiom and Terumo can help your organization both analyze your 90-day episode costs utilizing CMS claims data, as well as analyze your current processes and costs to deliver care. How efficient is your lab and how does your 90-day readmission rate compare to your Metropolitan Statistical Area (MSA) or to programs nationally? These combined assessments provide organizations an evaluation of their readiness and further identifies opportunities for programs to optimize their performance now and moving forward. We are helping programs develop their bundled payment strategy, assess their current capabilities and gaps in their readiness, and are even working with providers to take risk with their commercial carriers. While there are uncertainties about the timing and the details of how these payment models will move forward, the consensus is that we are accelerating toward value-driven payments and programs that position their organizations early will have an advantage, regardless of how these changes are implemented.

Conclusion

Ryan, thanks for taking time to share your insights and knowledge regarding cardiac bundles. I know this is something that our two organizations are tackling as we engage with various programs around the country. It certainly lends itself to how cath lab programs can meet the growing challenges of managing costs and profitability. It would only seem to make sense that regardless of the next administration, reducing costs, improving operational efficiencies, and leveraging ways to further improve patient satisfaction are keys to improving profitability, irrespective of whether we are looking at a CMS bundle or a private payer.  

References

1. CMS Releases 2015 National Health Expenditures. Available online at https://www.cms.gov/News room/MediaReleaseDatabase/Press-releases/2016-Press-releases-items/2016-12-02.html. Accessed January 3, 2017.
2. Congressional Budget Office. Bundle Medicare’s Payments to Health Care Providers. Available online at https://www.cbo.gov/budget-options/2013/44898. Accessed January 3, 2017.
3. Bieniarz MC, Beekman A. Initial experience with a redesigned care pathway. Cath Lab Digest. 2016 Dec; 24(12): 8-9. Available online at https://www.cathlabdigest.com/article/Initial-Experience-Redesigned-Care-Pathway. Accessed January 3, 2017.

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