In the days and months after a heart attack, a patient has a long list of tasks to remember as they recover: Take medications, eat nutritious foods, go to physical therapy, to name just a few.
This kind of post-acute care has long been viewed as outside the purview of the hospitals that treated the patient in the first place. But a new set of rules for cardiac bundled payments and rehabilitation, proposed Monday by the CMS, is likely to drive hospitals to pay far more attention to post-acute care, a shift that could pose fresh challenges in a healthcare system that in many ways remains disjointed.
“In order for hospitals to win under the bundled payment programs, they have to take a more proactive role working with the surgeons … to plan the discharge of the patient a little bit more carefully,” said Francois de Brantes, the executive director of HCI3, a not-for-profit organization that focuses on improving healthcare. “The challenge of hospitals is making sure they've got good relationships with post-acute care providers,” de Brantes said.
Under a proposed demonstration program that would start July 1 next year in 98 randomly selected areas, Medicare would pay hospitals under a bundled-payment model for coronary bypass surgery and treatment for heart attacks. The hospitals would get a set amount per medical episode to cover the hospitalization and all of the related care for 90 days after the patient is discharged.
That puts hospitals at financial risk for managing the quality and efficiency of care delivered by a variety of post-acute providers, including skilled nursing and rehabilitation facilities and home health agencies.
“If you're responsible for the 90 days, you can't say, 'The patient is discharged, that's not my responsibility,'” said Dr. Gary Kalkut, senior vice president of network integration at NYU Langone, which participates in the voluntary Bundled Payments for Care Improvement (BPCI) initiative.
The hospital started with joint replacements under that program and later added cardiac valve and bypass surgeries. “It forces providers to have closer interactions and relationships about the care of the patient, with anyone who touches that patient over a 90-day period,” Kalkut said.
For NYU Langone, that meant creating new lines of communication—among physicians, nursing facilities, physical therapists, other providers—that hadn't previously existed. The hospital developed a transfer document that everyone reviewed regularly for status updates on a patient.
With better post-acute care, treatment costs could be slashed by anywhere from 10% to 20%, de Brantes said, adding that the structure of the CMS' proposed cardiac bundled payment would push hospitals and physicians to be proactive.
As bundled payment programs have expanded, major hospitals started to implement programs to track patients' discharge and recovery, said Josh Luke, a USC professor who also founded the National Readmission Prevention Collaborative and the National Bundled Payment Collaborative.
“Traditionally, once a patient went home from the hospital after a cardiac episode, anytime they showed fatigue or discomfort, you immediately would return them to the hospital,” Luke said. Now, he said, hospitals have an increasingly robust array of incentives to get serious about follow-up care.
But deeper involvement in post-acute care won't necessarily be easy or smooth for hospitals, however. They might be located in areas that have a dearth of high-quality post-acute care providers, for instance—although, de Brantes noted, those hospitals wouldn't bear disproportionate risk under those circumstances.
The new model mitigates such risk for hospitals by basing the target cost of a procedure in part on geography. The base payment for procedures will transition from a mix of hospital-specific data and regional historic data in the first years of the five-year program to only regional data, in the final two years.
The program could drive other structural changes in the industry, too, particularly in conjunction with the growing numbers of patients who need post-acute care.
In 2008, the Agency for Health Research and Quality found a 53% increase between 1997 and 2006 in the rate of patients discharged from hospitals who needed home healthcare. Over the same period, the rate of patients who went from hospital to nursing homes or rehabilitation facilities rose 30%, the agency found.
The accelerating transition to value-based payment models could “challenge revenue streams for post-acute providers in the near team” and “drive further vertical consolidation within the post-acute sector,” according to an equity research note from J.P. Morgan.
The agency also proposed a model creating financial incentives for hospitals in 45 other geographic areas to put patients in cardiac rehabilitation programs.
Just 15% of heart attack patients use these services, which have been found to reduce the risk of a second heart attack or death, the CMS said. Under this initiative, Medicare would pay hospitals $25 per service for a maximum of 11 services.
The proposals are designed to emphasize health over treating a disease, Dr. Patrick Conway, acting principal deputy administrator and chief medical officer for CMS, said in a call with reporters Monday.
