Within the last few days, CMS/HHS sent a proposed rule to OMB (Office of Management and Budget) that would cancel the planned January 2018 roll-out of the (mandatory) cardiac and traumatic joint repair/replacement bundles. Specifically, CMS was adding bypass and myocardial infarction DRGs to the BPCI (Bundled Payments for Care Improvement) along with DRGs pertaining to traumatic upper-femur fracture and related joint repair/replacement. The original implementation date was March, then delayed to May, again delayed to October and then to January 2018. Additionally, the proposed rule (text yet available) includes refinement proposals for the current mandatory CJR bundles (elective hip and knee replacements). It is widely suspected that the mandatory nature of the CJR will revert to a voluntary program in 2018.
The question that begs current is this step a sign of hiatus for episodic payments or an all-out demise. Consider the following;
- The current head of HHS, Tom Price is a physician who has been anti the CMS Innovation Center’s approach to force-feeding providers, new payment methodologies. While Price is on the record as favoring payment reform he is also adamant that the same needs to incorporate the industry stakeholders in greater number and length than what CMS has done to date (with the BPCI).
- Evidence of true savings and care improvement has not occurred, at least to date. This is definitely true of the large-scale initiatives. The voluntary programs, in various phases, are demonstrating some success but wholesale success is simply not there or not yet confirmed by data.
- Providers have railed against bundle complexity and in particular, the short-comings evident for cardiac DRGs which are inherently far more complex than the orthopedic DRGs, at least those that are non-traumatic.
My answer to the question is “hiatus” for quite some time. While there is no question that value-based care and episodic payments are part of the go-forward reality for Medicare, timing is everything. There are multiple policy issues at play including the fate of the ACA. A ripple effect due to whatever occurs with the ACA (repeal, revamp, replace, etc.) will permeate Medicare (to what extent is yet to be determined). I anticipate the current voluntary programs to continue and CMS to return to the drawing board waiting for more data and greater clarity on “where to go” with respect to value-based care programs.
Finally, because bundled payments did have some implications for the post-acute sectors of health care, this possible change in direction will have an impact, albeit small. The cardiac bundles had little to no impact for SNFs or HHAs and only minor impact perhaps, for IRFs (Skilled Nursing, Home Health and Inpatient Rehab respectively). Traumatic fractures and joint repair/replacement had some impact for inpatient providers, particularly Skilled and IRFs as rarely can these patients transition home or outpatient from the surgical stay. Some inpatient care is customary and frankly, warranted.
CJR sun-setting may have some broader ramifications. Right now, CJR has shifted the market dynamic away from a traditional SNF or IRF stay to home health and outpatient. The results are evidenced by a fairly noticeable referral shift away from SNFs and concomitant Medicare census declines coupled with length of stay pressures (shorter). Home health and outpatient has benefitted. Yet to determine is whether this trend is ingrained and evidence of a new paradigm; one that may be permanent. If the latter is the case, CJR shifting to a voluntary program may not change the current picture much, if any. My prediction is that the market and the payers have moved to a new normal for voluntary joint replacements and as such, CJR or not, the movement away from inpatient stays and utilization is here to stay.