For the first time, the Obama administration is proposing to require hospitals to participate in a Medicare demonstration of an alternative payment model, a recognition that the voluntary approach isn't going to achieve the rapid shift it seeks away from fee-for-service.
Last week, the CMS identified 75 geographic areas, including Los Angeles and New York City, it plans to include in a mandatory test of bundled payments for hip and knee replacements, starting Jan. 1, 2016. More than 800 hospitals would be subject to the rule. Critical-access hospitals would be excluded.
Hospitals would continue to get paid for their services under Medicare's fee-for-service system. At the end of the year, however, there would be a bundled-payment reconciliation based on a hospital's quality and cost performance. The facility either would receive an additional payment or be required to repay Medicare for a portion of care episode costs. Hospitals would not be at risk in the first year.
The CMS said the program would give hospitals an incentive to work with physicians and post-acute providers to improve care coordination and reduce avoidable hospitalizations and complications. It would include quality measures for complications, readmissions and patient experience.
“We're doing this because we believe there's an opportunity to improve care for Medicare beneficiaries who are undergoing hip and knee replacements,” said Dr. Patrick Conway, deputy CMS administrator for innovation and quality.
Two prominent advocates of bundled payment applauded the announcement but urged the CMS to go further. Bundles should be used for spine surgery and other procedures, and the orthopedic bundles should be “the standard method of payment nationwide,” Dr. Ezekiel Emanuel, chairman of the department of medical ethics and health policy at the University of Pennsylvania, and Topher Spiro, vice president for health policy at the Center for American Progress, said in a written statement.
But Premier, the hospital purchasing, consulting and performance improvement company, said rolling out mandatory bundled payment was “too much, too fast.” Senior Vice President Blair Childs said a voluntary, national program would be better.
The American Hospital Association said it “looks forward to working with CMS to ensure the proposed rule meets the needs of our patients and individual communities.”