The Centers for Medicare and Medicaid Services (CMS) hopes to scale back its mandatory joint replacement bundled payment program and fully cancel its cardiac bundled payment programs before they even begin in January 2018.
In a proposed rule released in mid-August, CMS outlines its plan to reduce the number of mandatory geographic areas participating in the Comprehensive Care for Joint Replacement (CJR) model from 67 to 34, and to allow hospitals in the 33 remaining areas, as well as low volume and rural hospitals in all of the CJR geographic areas, to participate on a voluntary basis. As well, CMS proposed canceling the Episode Payment Models (EPMs) and the Cardiac Rehabilitation (CR) incentive payment model.
“Eliminating these models would give [us] greater flexibility to design and test innovations that will improve quality and care coordination across the in-patient and post-acute-care spectrum,” CMS said in a prepared statement.
For emergency physicians, bundled payments have always posed unique challenges.
“If a hospital system is able to design and implement a process for providing those patients within a bundled service to receive the acute episodic care they require in a timely manner we all benefit,” said William Freudenthal, MD, president of St. Vincent Emergency Physicians. “The challenging part will be designing the compensation model that is fair and equitable to all involved.”
According to the American College of Emergency Physicians (ACEP), visits to an emergency department are usually “not foreseen and thus are usually not accounted for in bundled payments. Therefore, the ED visits may be paid at a reduced FFS rate. These rates may or may not be negotiated in advance.”
In their comments to CMS in 2016 about the then-proposed episode payment models, ACEP highlighted some of the challenges of including ED care in such programs:
- “Defining the beginning of an ED encounter is done not by the emergency physician but by the patient when s/he presents for urgent care,
- “Setting boundaries for services included or excluded in an ED encounter is often impossible given the undifferentiated presenting complaints of patients seeking ED care,
- “Pricing ED care encounters is confounded when ED care leads to admission since services provided in the ED are often subsumed into payment for the admission (e.g., 3-day lookback); pricing is further confounded by the extensive testing that may be appropriately required to rapidly reach a diagnosis when a very sick patient seeks ED care for nonspecific complaints,
- “Emergency physicians are expected to hand off their patients to other physicians for definitive treatment, limiting the motivation for the latter group of physicians to engage in shared accountability with emergency physicians, and
- “Linking ED care quality to payment is confounded by the use of the ED visit itself as a failure metric in various existing models.”
With all of these barriers, is there even a place for emergency medicine in alternative payment models? Hopefully.
ACEP ended their comments about the Advancing Care Coordination Proposed Rule by expressing their willingness “to work with CMS in extending value based payment to the emergency care of Medicare beneficiaries.” And Dr. Freudenthal believes the way forward incorporates both clinical efficacy and cost efficiencies.
“I would like to see the industry move toward models of care which are evidence based as well as cost effective,” said Dr. Freudenthal. “It will be interesting to watch how this process unfolds in the next several years after the initial trials did not show the improvement in the quality of care that was expected.”
For more information or to submit comments about CMS’ proposed changes, review this CMS Fact Sheet.
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