Department of Health and Human Services Proposed Changes in Cardiac Care

Department of Health and Human Services Proposed Changes in Cardiac Care

The Goal: to Increase Quality and Cost of Cardiac Care



The Department for Health and Human Services (DHH) released new models for bundled payments related to cardiac procedures and patient care on July 25th of this year.  These new payment models are aimed to help improve the quality of care for cardiac patients while also making it more affordable, partially by incentivizing preventive and rehabilitative procedures.  DHH believes that these changes will be effective and has based them off of a similar pilot program that was designed to bring about the same changes in orthopedic hip replacement and other surgical hip procedures. 


The changes to the bundled payment models for cardiac procedures and follow up care are being discussed by many organizations and in many forums.  Main Street Medical Consultants is getting to the heart of these changes for our customers, to make this transition as smooth and painless as possible.


Three Proposed Changes:


1.    Proposed a bundled payment model for cardiac procedures based on the successful pilot program with hip replacements and other hip operations.  This pilot program worked so successfully that DHH is rolling out even more solutions for orthopedic hip care in this document along with the cardiac care payment changes.

2.    Proposed a new model to help increase the utilization of cardiac rehabilitation, which can reduce a patient’s need to seek major cardiac procedures in the future.

3.    Lastly it created a proposed pathway for affected physicians to qualify for payment incentives, under the Quality Payment Program.

What brought about these changes?

According to Centers for Medicare and Medicaid Services, “Heart attacks and strokes cause one in three deaths and result in over $300 billion of health care costs each year. [Sic]  The changes that are outlined in these three proposals are a direct attempt to lower the number of these episodes and therefore cut the cost it takes to treat them. 


The DHH believes that hospitals that work together in the coordination of care with the attending physicians and other medical professionals will help to avoid or cut down on the number of complications, to prevent the number of people readmitted to the hospitals and aid in the expedition of the individual patient’s recovery.


These proposals were based off of research which demonstrates that when all of a patient’s medical professionals, both inside the hospital and in outpatient care settings, work together, the treatment is more accurate, and is also more cost efficient, benefitting both the hospital and medical administrations and the patient.


Bundled payment solutions were tested in the 1990’s for bypass surgeries, where according to the Centers for Medicare and Medicaid Services, physicians were successfully incentivized which resulted in better, more efficient care reducing the cost of treatment.

Breaking it Down


Let’s take a closer look at each of these three proposals to better understand the changes that each will implement. 

Proposed Bundled Payment Model

At a very high level, the bundled payment model states the hospital to which a patient is admitted, is responsible for the cost care for patients who qualify as Medicare’s fee-for-service beneficiaries from the time that they are admitted, until 90 days after their discharge. 


For each care episode, a hospital will be paid a fixed target price.  This target price will be determined by the quality of care delivered by a hospital.  For example, hospitals that provide a high quality of care will be paid a higher set target price for each care episode.  Complexity of the health issue will be taken into account when determining the set targets.


At the end of every year, the quality of care provided by a hospital will be examined, and if a hospital has improved their care, they will be eligible for a higher target price in the following year, thus incentivizing hospitals to improve the quality of care provided to their patients. 


The bundled payments in this proposal will be phased into practice from July of 2017 through 2019.  For more information on the dates, requirements, examples of how these bundles work and an overall fact sheet from CMS please click here and general payment model information here.

Incentivized Use of Cardiac Rehabilitation Programs


According to many patients do not complete their post-operative or post care cardiac rehabilitation.  Kristen Barlow goes on to explain that many who do not utilize post care rehabilitation services cite their co-pays being too high as the reason.  Cardiac rehab incentive payments are believed to lower the cost of these important services and allow hospitals and medical professionals to make them more attainable to those who are in need of them.


CMS outlines two incentives here.  For participating hospitals, an incentive payment of $25 per cardiac rehabilitation service for the 11 services covered by Medicare after an event.  After these 11 services that are covered by Medicare, the payment for these continued services would increase from $25 to $175.

Quality Payment Program

The third proposal outlined in this 900 page document, is incentivized payments for which physicians may be eligible.  The Quality Payment program, which is responsible for these incentivized payments, is made possible or authorized by the Medicare Access and CHIP Reauthorization Act (MACRA).  Beginning in 2018, heart attacks and bypass surgeries would require participants to bear risk for monetary losses, use certain quality measures and to utilize Certified Electronic Health Record Technology. 


You can find more about the specifics of the incentive payment model here.