CMS Proposes Cardiac Payment Bundle and Expansion of CJR

On July 25, 2016 the Centers for Medicare and Medicaid Services (CMS) released a Proposed Rule for a new mandatory bundled payment model for cardiac care, an expansion of the Comprehensive Care for Joint Replacement (CJR) model and a Cardiac Rehabilitation (CR) incentive payment model. CMS also indicated that these proposed bundled payment models could qualify as Advanced Alternative Payment Models (AAPMs) beginning in 2018. The Proposed Rule has a 60-day comment period.

Episode Payment Models

Cardiac Care

CMS proposes creating a new episode payment model (EPM) for services surrounding an acute myocardial infarction (AMI), coronary artery bypass graft (CABG). The bundled episode will consist of virtually all related care from a beneficiary’s admission to a participant hospital to 90 days following hospital discharge, and hospital participation in the program will be mandatory in 98 randomly-selected metropolitan statistical areas (MSAs) chosen by CMS. The agency proposes to test the cardiac model for 5 performance years, beginning July 1, 2017, and ending December 31, 2021, and indicates that it will select the applicable MSAs in the forthcoming Final Rule utilizing market criteria that exclude certain rural MSAs from eligibility.

Expanded CJR

CMS also proposes to expand the current CJR payment bundle for joint replacement by adding additional procedures to the mandatory program. Under this proposal, the model would also include an episode designed around surgical hip/femur fracture treatment (SHFTT) that would be triggered by a discharge under MS-DRG 480 (Hip & femur procedures except major joint w/ MCC), 481 (Hip & femur procedures except major joint with complication or comorbidity (CC) and 482 (Hip & femur procedures except major joint w/out CC/MCC). Like the proposed cardiac model, CMS would test this model for 5 performance years, beginning July 1, 2017, and ending December 31, 2021, and participation would be mandatory in the same 67 MSAs that were selected for the CJR model.

The original CJR payment model was designed around lower extremity joint replacements episodes and was triggered by an admission to an inpatient hospital resulting in a discharge assigned to either MS-DRG 469 (Major joint replacement or reattachment of lower extremity with MCC) or MS-DRG 470 (Major joint replacement or reattachment of lower extremity w/out MCC). Additional MCDermottPlus analysis on the original CJR program can be found here.

CR Incentive Payment Model

The final component of this Proposed Rule is the CR incentive payment model which would test the impact of providing an incentive payment to hospitals where beneficiaries are hospitalized for a heart attack or bypass surgery. CMS proposes establishing a two-part CR incentive payment that would be paid retrospectively based on the total cardiac rehabilitation use of beneficiaries attributable to participant hospitals. These payments would be available to hospital participants in 45 geographic areas that were not selected for the cardiac care bundled payment models, as well as 45 geographic areas that were selected for the cardiac care bundled payment models.

Qualification as Advanced Alternative Payment Models (AAPM)

In the Proposed Rule, CMS also establishes two potential tracks for the three newly proposed EPMs as well as CJR under the physician payment methodology established in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA): an Advanced APM track and a non-Advanced APM track.

  • Track 1, the Advanced APM track: CMS proposes participants must use Certified Electronic Health Record Technology (CEHRT) as described in the recent Quality Payment Program Proposed Rule.
  • Track 2, the non-Advanced APM track: CMS would not require the use of CEHRT.

The different tracks would not change how EPM participants operate within the EPM itself, but providers could select to meet the requirements associated with the CEHRT use requirements to realize certain benefits under MACRA. For more detailed information on MACRA, the McDermottPlus overview can be found here.

For more information, the Proposed Rule is available here and fact sheet is available here.