Bundled payment models for coordinated cardiac and hip fracture care

September 15th, 2016 - Chris Woolstenhulme, CPC, CMRS
Categories:   Reimbursement  
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HHS is proposing new bundled payment models to improve the quality of care and reduce costs for beneficiaries who have a heart attack or undergo bypass surgery. HHS is also proposing to extend its innovative hip and knee bundled payment model to include other surgical treatments for hip and femur fractures beyond hip replacement. These new models support the Administration’s goal to have 50 percent of traditional Medicare payments flowing through alternative payment models by 2018 (already, 30 percent of Medicare payments go through alternative models).

Under the proposed episode payment models, the hospital in which a patient is admitted for care for a heart attack,(1) bypass surgery, (2) or surgical hip/femur fracture treatment (3) would be accountable for the cost and quality of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days after discharge.

Measures for transition

  • July 2017 – March 2018 (performance year 1 and quarter 1 of performance year 2):  No repayment;
  • April 2018 – December 2018 (quarters 2 through 4 of performance year 2): Capped at 5 percent;
  • 2019 (performance year 3): Capped at 10 percent; and
  • 2020 – 2021 (performance years 4 and 5): Capped at 20 percent.

Participants

For the new cardiac bundles, participants would be hospitals in 98 randomly-selected metropolitan statistical areas (MSAs). Hospitals outside these geographic areas would not participate in the model. There is no application process for hospitals for these models.

Because the hip/femur fracture surgeries model builds upon the existing CJR model, CMS proposes to test these bundled payments in the same 67 MSAs that were selected for that model. Rural counties are excluded from the models.

(1) Acute myocardial infarction (AMI) model episodes would be initiated by claims for AMI MS-DRGs 280-282 or claims for PCI MS-DRGs 246-251 with an AMI International Classification of Diseases (ICD)-Clinical Modification (CM) diagnosis code in the principal or secondary diagnosis code position.

(2) Coronary artery bypass graft (CABG) model episodes would be initiated by claims for CABG MS-DRGs 231-236.

(3) Surgical hip/femur fracture treatment (SHFFT) model episodes would be initiated by claims for hip and femur procedures, except major joint, MS-DRGs 480-482.

 https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-25.html

 

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