Monday, August 14, 2017

Brief Blog: CMS - Cancellation of Some Bundled Payment Programs PUBLISHED

Proposed Rule Published.  Online here.  Comment here.
Trade Press: here.  CMS Press Release here.

For more trade press:
  • American Journal of Managed Care, "CMS To Cancel Mandatory Cardiac, Expanded Joint Replacement Bundles," here.
  • Cardiovascular Business, "Cardiac Bundles to be Canceled by CMS," here.
  • Healthcare Informatics, "CMS Provides More Details on Proposal to Eliminate Mandatory Bundled Payment Programs," here.
  • Medpage Today, "Docs, Hospitals Respond to CMS Retreat," here.
  • Forbes (earlier, June 2017):  "Alternatives Are Needed to Flawed CMMI," here.
  • Healthcare Dive (Sept. 7):  "Scaling Back Bundled Payments Won't Stop Shift to Alternative Models," here.
In addition, on August 21, CMS announced it was cancelling one of the three tracks, the Awareness Track, in an Accountable Health Communities model that was announced as a $120M project in April 2017 (here; see bullet point on cancellation, here).   On August 24, Inside Health Policy (subscription) reported that a formal request for public input on CMMI's goals and direction may appear soon (here).

For a 250-page commissioned independent review of the successes and difficulties of smaller CMS initiatives, here.


The draft rulemaking has some interesting features.

  • Change of Administration.  They note the Agency has a right to revise its policies and especially with "a change in administration."   
  • (1) Some Programs Shrink.  They believe the older program, the Comprehensive Joint program, is in its second year but the number of mandatory metropolitan zones may be halved - and even where they remain, more hospitals excluded - while still obtaining valid statistical data on program savings for the Actuary. 
    • The only, or one of the only, statistically successful programs has been the Medicare Diabetes Prevention Program, which is being rolled out nationally in 2018 based on its cost-savings value in demo programs.  
    • In speeches, outgoing director Dr. Patrick Conway has bemoaned that numerous CMMI early programs failed to be rigorous enough or successful enough to meet the Actuary's criteria for expansion.
  • (2) Some Delayed Programs Are Now Killed. The newer programs have been delaying since the November 2016 election and are hereby canceled, although the Agency could revive parts of such programs at a future date if it sees fits.   
    • New Programs More Like Grants, Less Like Laws.  Likely, the rule notes, new programs would be voluntary and solicited by grant application or RFP rather than instituted as law by rulemaking.   However, if a couple voluntary centers embrace a demo program, it is harder to know if it is a benefit that is valid to roll out nationally, which is one of the reasons for the existence (raison d'etre) of CMMI.  
  • Frees Up CMMI Budgets?  Because the CMMI or Innovation Center has a finite budget, the sudden cancellation of some large programs might free up budget for other programs.
  • Telehealth Expansion by CMMI.  Notably, the joint replacement model includes home telehealth evaluation, a very important new kind of Medicare service.  It's represented by 9 G-codes which CMS is offering to pay a little more for (G9481ff).  
    • But the important thing is that tucked inside all the joint replacement demo program legalese is open access to home-based telemedicine.   Regular CMS telemedicine has very restricted sites of service. 
  • Making CMMI Program Expansion HARDER.  Congress gives CMMI the authority to create Demo Programs, and then to expand and extend them if they convince the Actuary that money is saved.   Very few CMMI programs have met the Actuary's standard for results and credibility, which you can glean from public CMMI documentation and from speeches of the outgoing director, Dr. Conway where he reiterates that CMMI program designs are not meeting the scrutiny of actuaries.   
    • CMMI makes this budget appraisal problem worse if it allows participants cherry pick themselves, making it harder for the Actuary to later certify that the programs would work on a nationwide, take-all-comers basis.  
    • If you don't eat your vegetables today (such as randomized trials and regionally mandatory enrollment zones), you won't get your dessert tomorrow (program expansion after savings certification.)

Original Article

Bundled payment programs are sometimes viewed as the messiah that can save us from the high costs of fee-for-service systems.   On the other hand, they have also been roundly criticized for poor design or lack of impact or both (here).

Healthcare Dive reports on August 14, 2017, that HHS may be proposing to cancel or heavily modify some bundled payment programs.   The Healthcare Dive article is here, citing a rule in process at the Office of Management and Budget here.  Coverage also at Axios, noting Secr. Tom Price's longstanding dislike of "innovative" CMS bundling programs (here). MedCityNews, here.

The rule has the title:  Cancellation of Advancing Care Coordination through Episode Payment and Cardiac Rehabilitation Incentive Payment Models; Changes to Comprehensive Care for Joint Replacement Payment Model (CMS-5524-P).

For a review of the "Mixed results" of payment reform experiments at CMS, also on August 14, see Nichols et al. at Health Affairs, here.  See also a Health Affairs article by Kahn, a couple days earlier, here.

The current director of the Innovation Center at CMS will be moving to a private sector position on October 1 (here).