Business Consult: CMS Targets Cardiovascular Care With New Mandatory Bundles | Deirdre Baggot, RN, PhD Principal, ECG Management Consultants, Tori Manis, Senior Manager, ECG Management Consultants

CardioSource WorldNews | In the June issue of CardioSource WorldNews, Deirdre Baggot, PhD, discussed how bullish the Centers for Medicare and Medicaid Services (CMS) is on bundled payments. At the time, Dr. Baggot stated that the expansion of existing bundled payment programs and creation of the mandatory Comprehensive Care for Joint Replacement (CJR) program clearly communicate CMS’s belief in bundles – and that cardiac-specific bundles were likely on deck.

Last month, CMS confirmed that prediction by announcing three new bundles, called episode payment models (EPMs), for acute myocardial infarction (AMI), coronary artery bypass graft (CABG), and hip/femur fractures. Additionally, a new program for increasing cardiac rehabilitation was also proposed.

The AMI and CABG bundles present new challenges and opportunities for cardiologists and cardiac surgeons. The model, as it is currently described in the proposed rule, will hold hospitals financially accountable for the cost and quality of medical and surgical care for the two events during inpatient stays and for 90 days following discharge. The proposed 5-year demonstration will go into effect on July 1, 2017. CMS identified 294 MSAs that will be eligible, 98 of which will be mandated to participate (MSA’s are expected to be named by year’s end).

We talked to Dr. Baggot, Principal, and Tori Manis, Senior Manager, with ECG Management Consultants’ Bundled Payments practice, about the program and what organizations can do to prepare for cardiac bundles.

Why did CMS select cardiovascular care for inclusion in its second set of mandatory bundles?

Conditions and procedures such as AMI and CABG are high-volume and high-cost for Medicare. They also tend to have fairly high readmission rates, which CMS especially wants to curb. For an AMI episode, there is an average 20% readmission rate, which accounts for half of the estimated costs. For CABG, approximately 75% of costs are hospital-based, with the majority of the post-discharge costs being related to readmissions. So, CMS clearly sees an opportunity here to reduce costs and improve outcomes.

CMS’s first mandatory bundled payment program focused on orthopedic procedures. How are cardiac bundles different from CJR?

With CJR, most joint replacements are elective and planned weeks ahead of time, enabling providers to predict and often avoid or minimize clinical variation. There’s sound evidence that elective procedure bundles can standardize care and save money. But bundling heart attack care is a very different exercise. Heart attacks are unpredictable, require immediate treatment, and are followed by high readmission rates. The effectiveness of bundles for emergent episodes has not been tested and needs more study. Adding emergent procedures is a testing ground for CMS, and it will be interesting to follow the clinical and financial results.

The AMI bundle would seem to pose particular challenges, given the unpredictability and high readmission rates for heart attacks. How can organizations prepare?

Certainly, there needs to be emphasis on care coordination and post-discharge follow-up. Care transitions during the post-acute period need to be managed and minimized.

Improving communication between the ER and the surgeons, physicians, and clinical team members who are going to be taking care of these patients is essential — again, care coordination.

Organizations also need to gather and review data – internal data, system data, national benchmark data. Quantifying volume or the number of cases, which physicians are participating in the patient’s care, and what are the biggest drivers of cost in an episode. Organizations can use data to identify and eliminate variation wherever it’s clinically unwarranted, or conduct an initial evaluation to identify avoidable readmissions.

Who stands to benefit from these new bundles, and from bundles more generally?

Despite the seemingly chaotic reimbursement environment, bundled payments are a safe bet. Bundles truly represent one of the few reimbursement approaches today through which all stakeholders can benefit. The ultimate goal of this initiative is to standardize patient care, improve outcomes, and enhance the quality of care delivered to Medicare beneficiaries, as well as all patients. Certainly, patients benefit by having access to standardized, evidence-based care. If hospitals are willing to do the hard work associated with bundles, they stand to benefit financially by lowering their costs. The physicians or surgeons involved in the patient’s care can also see financial benefits from the gain-sharing waivers that are put in place as part of these programs. And of course, Medicare has already experienced significant savings as a result of the bundled programs that are in place today.

What other insights can you share with cardiologists?

If you’re treating the Medicare population and you’re in one of the prospective MSAs that CMS identified, your hospital could be chosen. You absolutely need to be paying attention to this development and, at the very least, take a look at your historical costs. Don’t wait to see if your hospital is named – assume it will be. Organizations that want to succeed will be engaged in the process and proactively manage the potential for risk.


For questions or want more information on bundled payments, contact Dr. Baggot at dbaggot@ecgmc.com or Tori at tamanis@ecgmc.com.

Read the full September issue of CardioSource WorldNews at ACC.org/CSWN

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention

Keywords: CardioSource WorldNews, Centers for Medicare and Medicaid Services (U.S.), Coronary Artery Bypass, Health Expenditures, Inpatients, Medicaid, Medicare, Myocardial Infarction, Surgeons


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