Value Based Care Models

This year (2017) CMS is adding yet another layer to their value-based payment incentive program. In July, CMS will be introducing the first bundled payment models for cardiac care. These models will include AMI & CABG as well as a cardiac rehab incentive program. In addition to these models they will introduce the SHFFT model (Surgical Hip and Femur Fracture Treatment), to expand on the CJR bundles that were introduced last year.

The final rule, which was released on Dec. 20th 2016, has selected 98 Metropolitan Statistical Area (MSAs) to participate in these new bundled payments, which have been identified as Episode Payment Models. Those 98 selected MSAs can be found in the embedded table below or viewed on the CMS website here.  For these MSAs, this represents a significant change in how hospitals approach the delivery of care for PCI and CABG patients.  Now is the time to start predicting and preventing poor outcomes and truly control costs.

The models will begin on July 1st 2017, and will extend through the year 2021.


Target Pricing

The new EPMs will focus on setting target prices for episodes of care, from episode admission to 90 days post-procedure. CMS is introducing these “target” prices in order to reduce variability across systems, and procedures.

For the first two years, to determine target prices, CMS will take into account the historical hospital data, as well as regional data. For the first 2 performance years, they will use a combination of 2/3 hospital historical data, as well as 1/3 regional data. Year 3 will reverse this, using 1/3 hospital data and 2/3 regional data. For years 4 & 7, they will solely use regional data.

The target prices will also be adjusted based on the hospital’s quality performance.

Acute Myocardial Infarction (AMI)

The AMI bundles will begin with hospitalization for AMI, and will extend for 90 days after discharge from the hospital. The MS-DRGs that are included in the bundle are as follows:

  • MS-DRG 280 (Acute myocardial infarction, discharged alive with MCC)
  • MS-DRG 281 (Acute myocardial infarction, discharged alive with CC)
  • MS-DRG 282 (Acute myocardial infarction, discharged alive without CC/MCC)

In addition to AMI MS-DRGs, patients treated with percutaneous catheter insertion (PCI) for AMI will also be included:

  • MS-DRG 246 (Percutaneous cardiovascular procedures with drug-eluting stent with MCC or 4+ vessels/stents)
  • MS-DRG 247 (Percutaneous cardiovascular procedures with drug-eluting stent without MCC)
  • MS-DRG 248 (Percutaneous cardiovascular procedures with non-drug-eluting stent with MCC or 4+ vessels)
  • MS-DRG 249 (Percutaneous cardiovascular procedures with non-drug-eluting stent without MCC)
  • MS-DRG 250 (Percutaneous cardiovascular procedures without coronary artery stent with MCC)
  • MS-DRG 251 (Percutaneous cardiovascular procedures without coronary artery stent without MCC)

During an episode of care, the hospital will be financially responsible for the cost of the procedure, aiming to meet the target price set by CMS. It is important to understand where the majority of cost is incurred for each model. As you can see, the majority of the costs are incurred at the episode initiator, but hospital readmission, and post-acute care also heavily impact cost.

HOS has developed a program called ePRISM, that helps reduce variability, and cut costs in these particular areas. ePRISM delivers actionable data, at the point of care to assist in meaningful quality and cost decisions. Learn more about the AMI model here.

Coronary Artery Bypass Graft (CABG)

The CABG bundles will begin with hospitalization for CABG, and will extend for 90 days after discharge from the hospital. The MS-DRGs that are included in the bundle are as follows:

  • MS-DRG 231 (Coronary bypass with percutaneous transluminial coronary angioplasty (PTCA) with MCC)
  • MS-DRG 232 (Coronary bypass with PTCA without MCC)
  • MS-DRG 233 (Coronary bypass with cardiac cathertization with MCC)
  • MS-DRG 234 (Coronary bypass with cardiac cathertization without MCC)
  • MS-DRG 325 (Coronary bypass without cardiac cathertization with MCC)
  • MS-DRG 326 (Coronary bypass without cardiac cathertization without MCC)

The vast majority of costs incurred for CABG come from the episode initiator. In order to meet the prices set by CMS, great care will have to be taken during this phase to meet requirements.

In order to better asses the risk of these patients, ePRISM is deploying new models from the Society of Thoracic Surgeons that will help organizations determine the risk of a particular patient undergoing a CABG procedure. ePRISM delivers actionable data at the point of care to assist in making meaningful cost and quality decisions. Learn more about the CABG model here.

Surgical Hip and Femur Fracture Treatment (SHFFT)

The SHFFT model will begin with hospitalization for SHFFT, and will extend for 90 days after discharge from the hospital. The MS-DRGs that are included in the bundle are as follows:

  • MS-DRG 480 (Hip and femur procedures except major joint with major complication or comorbidity- CC).
  • MS-DRG 481 (Hip and femur procedures except major joint with complication or comorbidity – MCC).
  • MS-DRG 482 (Hip and femur procedures except major joint without CC or MCC).

According to CMS, this model will be implemented in 67 geographic areas, that are defined by MSAs. A list of those selected areas can be found here.  This model is an extension of the CJR bundles that were introduced in April of last year. The final rule states that a substantial amount of dollars are used in hospital readmissions. Post-acute care provider spending was also high. You can learn more about the SHFFT model here.

HOS is working towards implementing new models into ePRIMS that will help assess risk for the SHFFT model, as well as other joint replacement models.

Cardiac Rehabilitation (CR) Incentive Payment Model

The cardiac rehabilitation incentive payment model has been put in place to encourage and enhance rehabilitation 90 days-post cardiac care. This incentive program will encourage hospitals and providers to offer and improve rehab programs for patients who have undergone treatment for Heart Failure. CMS has created a retrospective repayment program, that will give providers money in these ways:

  1.  CMS will give initial payments of $25 for the first 11 cardiac rehabilitation services offered.
  2. CMS will give $175 after the first 11 services, limited to 36 sessions.

This program will be implemented in 90 geographic areas. To learn more about the CR incentive program, click here.