Dr. Glenn Hirsch on Bundled Payments for Cardiology

Following CMS’ proposed model for bundled payments in cardiology, we sat down with Dr. Glenn Hirsch, M.D., M.H.S., F.A.C.C., clinical director for the Division of Cardiovascular Medicine at The University of Louisville. Dr. Hirsch navigates the evolving regulatory landscape every day and knows firsthand what these changes mean for providers. As the Administration seeks to have 50 percent of traditional Medicare payments based on alternative payment models by 2018, Hirsch urges providers to work with their practice and local systems to act now. Keep reading to learn more about the proposed rule, what it means for providers, and how to respond.

1. How is this cardiac care model different from what we’ve seen around the Comprehensive Care for Joint Replacement (CJR) model for joint replacements?

Both models are similar in that they will drive value-based care and address episodic treatments. As the industry moves away from a fee-for-service model, we’ll likely see bundled payment models like these permeate not only orthopedics and cardiology, but also maternal care, oncology, and other specialties. In fact, CMS has already identified 48 types of treatment for this form of reimbursement in the Bundled Payments for Care Improvement Initiative. There are a few key differences between bundled payments for joint replacements and cardiac care, however.

First, the CJR model is mandatory for the geographic areas it affects, whereas the cardiac care bundles for a heart attack, also known as a myocardial infarction (MI), and coronary artery bypass surgery will not be mandatory until July 1, 2017.

Second, payments for cardiac care will be risk adjusted for patients based on the severity of the illness. For instance, an episode of care to treat an MI in a patient with multiple comorbidities such as diabetes, kidney disease and older age is different than what’s required for a young tobacco-smoking patient with no other health issues, and risk adjustment should allow appropriate reimbursement based on the risk and predicted associated costs. The cost for a heart attack hospitalization could vary by as much as 50% for Medicare beneficiaries, and CMS hopes this proposed rule will address that variation by adhering to best practices that lead to improved outcomes and savings. Providers will need to reduce the variations in care and communicate effectively with the entire care team to standardize care across the episode.

Third, cardiac bundles will apply to more hospitals than CJR, affecting 98 randomly-selected geographic areas, rather than the 67 that CJR touches.

2. Should cardiologists be planning for bundled payments now? If so, what should they be doing?

Yes, the time to start preparing for bundled payments is now because of the complexity in managing patients across an entire treatment episode. The industry is moving quickly towards value-based care, and those who don’t prepare now will be left behind, holding substantial financial risk.

Start thinking about how you’ll coordinate care among ALL members of a care team such as clinicians, nurse practitioners, pharmacists, social workers, post-acute facilities, care partners, and at the center of it all, the patients and their families. Consider your existing healthcare information technology and whether your systems are interoperable and transparent. A healthcare system can often lack visibility into patient information, not only from other systems, but from other providers within its own walls. Lastly, make sure you have the processes and infrastructure in place to become data-driven. These CMS regulations will require providers to report on quality and outcome metrics, so the more time spent getting your systems in order now, the easier and more successful the transition will be.

3. What’s the most important ingredient to success with bundled payments?

I believe it is care coordination, and that is a challenge in many environments as patients receive care at different sites who do not currently collaborate. With the time crunch we all face and the current reimbursement models, providers often do not communicate with each other across health systems, or even within the same system. We must improve upon this and connect the silos to remove fragmented care, which is a leading cause of inefficiencies, errors, and even poorer patient outcomes. By bringing teams together and helping them communicate, and giving them the access to data they need, we’ll be better equipped to meet bundled payment requirements.

A big part of the solution involves interoperability between IT systems. Although surprising, it is not infrequent that a patient who has had several hospitalizations does not know which hospital they were taken to after a heart attack or where their labs were sent. Meanwhile, their doctors cannot access patient data from an office that could be across the street, and they may even be unaware that their information is sitting there, since it is on a different system’s records. Even when made aware, accessing that data could mean a written request followed by a faxed patient record and a process that needs to be repeated with every new request. Very cumbersome. We need a way to document information directly into an electronic medical record (EMR), track interactions, and give the entire care team access to that data across systems, at least within our geographic region.

There is progress around interoperability, however. Congress has passed legislation to forbid intentional information-blocking of electronic health information, and I think we’ll continue to see a shift towards connected systems and better access to data.

4. What is the biggest pitfall to avoid when it comes to bundled payments?

The biggest pitfall I see is taking a “head in the sand” approach and not assessing how one’s own practice or hospital system will need to change to accomplish this level of care coordination and quality of care data capturing. People are currently accustomed to the fee-for-service model, but it is clear that the model is not sustainable and CMS is going to force change through reimbursement strategies. Practices that do not anticipate appropriate steps to prepare now could pay down the road.

5. How can hospitals know if they’re impacted by the regulation?

The CMS website is the best source of data to understand how your organization will be impacted. There, you can find FAQs, fact sheets, press releases, and more.