Guest Columns

It's time to bundle up

Kristy Brown
Kristy Brown

As we are moving towards new payment systems, it is imperative that we are involved and offer comments when we are able to as this will greatly impact us as providers. We also need to stay informed so we can modify our policies and procedures to be reflective of the changes.  

As noted by Ashish K. Jha, M.D., MPH in the JAMA Forum of August 4, 2016, the Centers for Medicare & Medicaid Services “has experimented with 30-day bundles for the last several years… the effect of this program, which has had only modest participation, is largely unknown."

Still, CMS has marched forward with creating bundles that have become more inclusive of post acute care in addition to hospital care with the Comprehensive Care for Joint Replacement which began April 2016. Now, the CMS proposal for a Cardiac Care Bundle (Acute Myocardial Infarction and Coronary Artery Bypass surgery) is due to take effect July 2017. 

Additionally, CMS proposed to include hip and femur fracture surgery as an addition to CJR. Together, these bundled episode proposals extend for 90 days beyond acute care discharge and include all necessary health services.

After applying exclusion criteria, CMS has identified 294 Metropolitan Statistical Areas (MSAs) which are identified on Table 1 of the proposed Cardiac bundle (pages 102 – 112). This is movement toward what CMS ultimately wants to see, called an Episode Payment Model.

Quality measures will be a large part of reported success for these proposed bundles and what CMS proposes for AMI, mortality, patient experience, and the number of days a patient spends in the hospital. For CABG surgery, CMS proposes to focus on mortality and patient experience. For fracture surgeries, CMS will assess quality using a mix of complication rates, patient experience, and voluntary reporting of patient-reported outcome measures (PROMs).

Good questions to ask yourself include what quality metrics do you currently perform and how that might contribute to the CMS proposal. For instance, in rehabilitation there are well over 500 functional outcome measures. Which ones do your therapists utilize? Are the measures grounded in strong evidenced-based practice? Will these measures be meaningful to the cardiac rehabilitation provider or do you need to better align yourself with the acute care and phase two cardiac rehabilitation providers?

As providers, how do we know if we are prepared to not only offer these services under this bundle but also provide the expertise that is needed? We need to start thinking about which outcome measures we most need to use. In asking ourselves this question, we should first look at what CMS wants in exchange for this payment. Some criteria, like the number of days spent by a patient in the hospital, are easier to measure than others. To measure patient experience, we will need the participation of patients who share their views.

We should also ready ourselves both operationally and clinically to provide services. Simultaneously, we need to solidify those relationships with Accountable Care Organizations and keep them informed of what we can provide and that we are ready to work with them.

As we consider bundled payment programs, some considerations for comments may include:

  • Standardization of measures: Since the proposed rule lays out a plan to base the target prices for bundle incentives on regional pricing in five years, should all quality measures be standardized, thus creating an even playing field with the best measures possible?

  • What quality measures would you recommend?

  • What is the impact on you if you are an independent provider and not part of a vertically integrated health system?

  • How much will CMS reimburse for the cardiac care bundle of service and how does this differ from the comprehensive care for joint replacement?

While change is never easy, therapy companies and other health care providers who have not thought about bundling issues should begin thinking about them as soon as possible. Changes in payment systems are not going away. It is to our advantage to plan for them and work on making the transition as seamless as possible.

Kristy Brown is the CEO and president at Centrex Rehab. 

 

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