Hospitals say a proposal to have them notify patients that their coverage may have changed as a result of an alternative payment model would result in high penalties and be costly to administer.
They say the CMS should be on the hook for informing enrollees.
In a July proposal to make 98 markets financially accountable for the cost and quality of all care associated with bypass surgery and heart attacks, the CMS made providers responsible for notifying patients.
Hospitals would explain the model, advise beneficiaries and their families of their care-delivery choices and clearly specify any non-hospital provider to avoid out of network costs and bills.
Such outreach “is essential because under the proposed [pay models], there would be a change in the way participants are paid, which could affect the care beneficiaries receive,” the CMS said in the rule.
Industry leaders are livid over the proposals and most agree that the CMS should be the one to notify beneficiaries. Most of the 178 comments made on the cardiac model proposed rule by its Oct. 3 deadline were negative.
Hospitals will need to generate lists of the beneficiaries who need to be notified, provide lists of participating providers and suppliers, and ensure that downstream providers provide appropriate notices to beneficiaries. That's overwhelming, said Tamra Minnier, chief quality officer at UPMC, a Pittsburgh-based health system.
The Hospital Corporation of America, which operates 169 hospitals and 116 freestanding surgery centers across 20 states, said it would be too heavy of an administrative burden to identify patients for the correct pay model. Making matters worse is that each pay model has different notification requirements.
Participating HCA hospitals may not know a patient is a bundled payment or shared savings beneficiary until post discharge since the final Medicare Severity-Diagnosis Related Group, which classifies a patient's hospital stay, is not assigned until three days after the patient leaves the hospital.
Because patients needing bypass surgery or having a heart attack are under such duress, they might not be notified in a timely manner, warned Dr. Jonathan Jaffery, senior vice president and chief population health officer at UW Health a regional health system in the Upper Midwest.
“We believe that the efficiency of the notification in this population would be improved outside of the setting of the emergency room/admission process,” Dr. Anthony Sorkin, System Medical Director for IU Health Orthopedic & Sports Medicine Service Line said in a letter to the CMS.
“As the insuring entity, Medicare is in the advantageous position of knowing all of the beneficiaries prior to the onset of an acute event and hospitalization.”
Sorkin suggests notification be made through the annual “Medicare & You” handbook mailed to all Medicare beneficiaries. An insert could explain which CMS demonstration projects and alternative payment models are being tested in their metropolitan area and describe how it may impact them.
Dr. Jonathan Perlin, HCA's chief medical officer said it will be especially important for the CMS to notify patients in an alternative pay model if they go to a skilled nursing facility.
In the new payment models outlined in the proposed rule, the CMS would waive the required three-day hospital visit before Medicare pays for an SNF as long as the facility has at least three stars on Medicare's five-star quality ratings.
If a patient goes to a lower-scored facility, hospitals, not Medicare would pay for the care received.
“As a result of the difficulties faced by participant hospitals in timely identifying bundled payment beneficiaries, HCA believes it would unfairly penalize participant hospitals," Perlin said.