Grumbling Over Bundling: Cardiologists React Warily to Plans for Lump-Sum Payments for Cardiac Care

In July, the US government announced its plan to alter reimbursement for heart disease treatments—specifically to bundle Medicare payments related to MI care and to bypass surgery. The response from cardiologists and their professional societies—the very people whose day-to-day choices and dreaded admin time will be most affected—could be politely summarized as a grumbled: “Say what?” 

At the time, statements were issued to the media and interviews were given to mainstream outlets like the Wall Street Journal, but few spokespeople appeared to have actually read through the meat of the 906-page document detailing the changes. The proposal, released by the Department of Health and Human Services (HHS), has been open to public comment, but more than a month after its online publication, only eight individuals have actually responded to what could be a preview of what’s to come in cardiovascular medicine.

Bundled payments, which refer to the reimbursement model wherein healthcare providers are paid a lump sum for each "episode” of care, are a decades-old concept. But most efforts to date have either been voluntary, such as the Bundled Payments for Care Improvement (BPCI) program, or started by private insurers. Last summer, however, the Centers for Medicare & Medicaid Services (CMS) first released tentative details on the Comprehensive Care for Joint Replacement program, which mandated bundled payments for hip and knee replacements and is currently being revised. This model is now being applied to cardiac care.

Muted Reaction

Just this week, the Society for Cardiovascular Angiography and Interventions (SCAI) publicly released its official response to the proposed rule. Among other things, SCAI’s letter takes on issues related to quality measures, outpatient PCI, multivessel revascularization, DES versus BMS, and the length of time that should fall under a single episode of care.

Unlike CABG, which has a long history in this arena, the implications for MI—an acute condition with myriad presentations and levels of complexity—are less obvious, said SCAI President Kenneth Rosenfield, MD (Massachusetts General Hospital, Boston, MA), who signed the group’s letter to CMS.

Speaking with TCTMD, Rosenfield allowed that CMS’ proposed program may well lead to better outcomes, increased efficiency, and lower costs. But it should be implemented with “extreme caution,” he said, “recognizing that this is somewhat of an experiment and we don’t know what the outcomes will be.” What we don’t want to do, he added, is to inadvertently reverse some of the gains in preventing and treating MI that have been made over the past two decades. 

Some variations in cardiovascular disease management and treatment stem from the “incredibly wide spectrum of illness amongst patients,” Rosenfield stressed. “Some are very straightforward [cases] that require less treatment. Others have very complex and challenging situations [that] can be managed with great success but require enormous resources to do so. And distinguishing between those patients upfront can often be difficult.”

Healthcare system expert and interventional cardiologist Andrew Ziskind, MD (Chicago, IL), agreed that the new proposal represents a shift. “As we move towards bundled payments,” he said, “what’s unique here is that now we’re including diagnoses that are much more complex and diverse clinically than what has been done in the past.”

Cardiologists need to be prepared, Ziskind advised, for the changes afoot.

The Plan

As reported earlier this summer by TCTMD, hospitals would be accountable under the plan for the cost and quality of care provided to Medicare fee-for-service beneficiaries in these categories—acute MI care and CABG—both during the inpatient stay and for 90 days after discharge. Participating hospitals would be paid per “care episode,” and those delivering higher-quality care would be paid at a higher rate. Hospitals that find ways to deliver the care for less than the quality-adjusted target price, “while meeting or exceeding quality standards,” will be paid for the savings achieved. On the other hand, hospitals that exceed the target price would be required to pay back Medicare for the cost overruns.

Via the official CMS blog this week, the agency’s head, Patrick Conway, MD, articulated his position on why such payments are a positive move.

“Patients want the peace of mind that comes with knowing they will receive high quality, coordinated care from the minute they are admitted to the hospital through their recovery,” he wrote. “Bundling payments for services that patients receive across a single episode of care—such as a heart bypass surgery or hip replacement—encourages better care coordination among hospitals, doctors, and other health care providers. Providers participating in bundled payments must work together when patients are in the hospital as well as after they are discharged, which should improve their recovery and avoid preventable complications and costs by keeping people healthy and at home.”

These models have already demonstrated their potential to improve the quality and cost-effectiveness of care, Conway said, noting that more than 1,400 providers are now participating in bundles through the BPCI program. In particular, cardiovascular surgery performed under BPCI has held steady in terms of quality, though it has not yet resulted in savings, he reported.

But SCAI’s letter to CMS questions a number of the plan’s specific elements. For one, it calls for more robust clinical data to be used to evaluate the reasons behind patient outcomes, suggesting that CMS use the American College of Cardiology’s National Cardiovascular Data Registry as its source. The group also recommends narrowing the window from 90 days to 30 days, based on the argument that most adverse events after acute MI occur within the smaller time horizon.

A big sticking point for SCAI seems to be how to handle multivessel revascularization in STEMI. Based on current guidelines, “AMI patients with multivessel disease often should get a secondary PCI procedure but this bundling effort will discourage the recommended course of care,” the SCAI letter states. “This bundle will encourage the treatment of secondary lesions during the initial angioplasty and in other cases there will be an incentive to delay treatment of the secondary lesions until after the 90[-day] bundle has expired. Another strategy to cope with the capped payments under the bundling strategy might be to inappropriately refer more multivessel patients into the separate CABG bundle.”

According to SCAI, it is also important that “CMS should take steps to ensure that the financial models used here do not discourage the appropriate use of DES,” which are more expensive than BMS. “If the [plan] causes fewer patients to receive DES, long-term outcomes may deteriorate and overall costs may grow,” the group says.

How to handle the complexities of transferred patients and provide cost-effective follow-up care postdischarge are also mentioned.

Continuity in Care

While CMS may well be receptive to some of the critiques submitted online, its proposal will probably move forward, at least in some fashion, after the 60-day public comment period ends, Paul Casale, MD (NewYork-Presbyterian Hospital, New York, NY), predicted to TCTMD. Nor should the plan come as a surprise, given how many Medicare patients have cardiovascular disease, he added. “These types of bundle initiatives are a way to engage specialists in this whole movement toward value-based care.”

Casale, who chairs the American College of Cardiology’s MACRA task force, believes physicians likely won’t see too many changes to their day-to-day routines but said some hospitals might need to up their game when it comes to infrastructure connecting cardiologists, social workers, primary care physicians, and others. In particular, he noted, this means “trying to enhance the coordination of care once patients leave the hospital. And depending on the health system, and how well integrated physicians are with each other or with the health system, there is variation around how well that coordination of care occurs. Having a program like a bundled payment program brings all the members of the team together to think through how to optimize communication and coordination.”

These efforts will likely offer the chance to try creative approaches like telemedicine, Casale noted. “Not all communication with patients needs to be face to face.” In a similar vein, the SCAI letter suggests testing whether “greater coverage of home visits with less physician supervision” might be helpful.

But Ziskind said some clinicians and hospital administrators may be surprised by how much they need to adapt to the new expectations.

“Most of the early movers in bundled payments were shocked to realize that you could standardize hospital care and processes and pathways but it was the postacute management where most of the variation and most of the cost was present,” Ziskind observed. “Some,” he added, “had a really hard time under bundled payments and it was because they couldn’t control the costs after the patients went out of the hospital.”

Postdischarge, patients return to primary care providers in geographically diverse areas and see other providers who “aren’t tightly aligned,” he explained. “So one critical success factor is the need to really get serious about coordinating postacute care.”

Another important factor, Ziskind said, “is the critical role of proper coding. This sounds like it’s just a nuts and bolts billing thing, but it’s not at all.” The ability to know whether you are delivering the right quality of care at the right cost “depends on properly documenting and coding all the comorbidities,” he continued. “There are many hospitals and health systems where coding sits in the basement and is kind of done after the fact. From my perspective, it is much more helpful managing bundled payments to get the coding out onto the floor and be much more contemporaneous, . . . because the accuracy will significantly better.”

A third ingredient to success, Ziskind added, is being able “to really track and measure costs. When we look at cost reporting systems and financial analytic systems like Strata, the ability to now give physicians near real-time feedback on how they’re doing and let them make adjustments—it has to be timely, it has to be attributable, it has to be accurate on both costs and quality—that’s how you start to tighten the system up.

Finally, Ziskind said the infrastructure must be in place to measure outcomes, though he predicted that given the extensive cardiovascular registries already in existence, “that’s probably not the weak link” for the field.

The Specter of the ‘Sickest Patients’

With the experience of mandatory public reporting—and the knowledge that it seems to affect patient care and outcomes—cardiologists aired concerns to TCTMD about how CMS would handle risk adjustment.

For example, it’s unclear how the bundled payments will account for differences among cases, “so that cardiologists and hospitals are not penalized for taking care of the sickest patients,” Casale said.

Risk adjustment helps, Rosenfield concurred, but it doesn’t go far enough. “What I would say is that the proposed bundles must adequately accommodate the needs of those sickest patients, who often actually, by the way, benefit the most from treatment that interventional cardiologists can render.”

For bundling to be successful, it must somehow allow for decisions to be made on a case-by-case basis when needed, he argued. “Every single patient is different. And how does one implement a program that makes a broad swath among patients while still accommodating the needs of individual patients? That is a challenge we face as a country, as a healthcare system. . . .We need to grapple with it.”

Moreover, he added, “patients need to be aware of what the system is directing them to do, or directing their doctors and providers to do.” In what he called the “era of capitation” of the 1980s, when physicians were paid per patient regardless of the care given, Rosenfield said “patients weren’t really aware that certain treatments were being withheld because their doctor or their healthcare system or their insurance provider was going to lose if they rendered certain treatments.”

Even now, he said, “every day of my professional, clinical life I encounter the same situations, where patients are being denied access to certain treatments because their third-party payer is going to be disadvantaged somehow, or they perceive they’re going to be disadvantaged, by [allowing] a treatment to happen.”

Battling this takes an enormous amount of time and resources, Rosenfield observed. “I understand that we need to be responsible stewards of the healthcare dollar, because it is a limited resources, but that responsibility lies with all of us and we need to do it as a team.”

‘The Final Push in the Back’

Possible solutions to varying risk levels are having an “out clause,” where particularly risky patients are exempt from the bundles, or institution-based review boards that can weigh the options, Rosenfield suggested to TCTMD. At Mass General, for example, “when we have such a difficult, challenging patient, we convene a multidisciplinary team—cardiac surgeon, interventional cardiologist, noninvasive cardiologist, and in some instances ethicists and palliative care [specialists] and sometimes family—and we . . . come to a consensus about the best approach,” he said.

The exact details of the CMS plan, such as whether riskier patients can essentially max out of the per-episode payment and fall under a fee-for-service reimbursement model, will affect how it plays out, Ziskind said. This is particularly relevant as providers start working with private insures to hammer out details on contracts, where there is an ability to negotiate the terms of the agreement. When Medicare proposes a model, the commercial payers usually follow suit, he noted.

“Many of the existing bundled payment contracts will exclude patients who have a lot of other medical problems going on,” he explained. This is why providers need to be able to document whether there are things that place a patient in versus out of the bundle.

As the US healthcare system transitions into novel forms of reimbursement meant to incentivize quality at lower cost, Ziskind predicted that many physicians may find it more difficult to maintain private practices. “It is increasingly hard, as payment models shift risk to provider organizations to remain independent,” he said. MACRA, or the Medicare Access and CHIP Reauthorization Act of 2015, “is that last final push in the back for independent physicians in small groups to become employed.”

Two months have passed since CMS first floated its plans—enough time, presumably, for cardiologists and administrators to wade through the document and figure out what they like and dislike about the proposal. The final plan would be phased in over a period of 5 years, starting first in 98 randomly chosen metro areas as of July 2017. These regions amount to around one-quarter of all metro areas in the United States, according to the HHS.

Anyone with skin in the game has just 10 days left to publicly voice any last gripes or questions on the proposal on the government website. The window for public comment closes on October 3, 2016. 

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Correction: An earlier version of this story mistakenly identified Paul Casale as John Casale.