Providers want over­haul of Medi­care hip, knee pay­ment test

Modern Healthcare - - NEWS - By Vir­gil Dick­son

Providers say a CMS model to have 800 U.S hos­pi­tals par­tic­i­pate in a test of bun­dled pay­ments for hip and knee re­place­ments would have to be changed sig­nif­i­cantly in or­der to suc­ceed.

The five-year pro­gram would be­gin Jan. 1. Nearly 300 com­ments on the pro­posal were re­ceived be­fore the dead­line last week. A re­cur­ring com­ment was that it was manda­tory, which the Fed­er­a­tion of Amer­i­can Hos­pi­tals op­posed. Some said it would pre­vent providers from tai­lor­ing care to their pa­tient pop­u­la­tion and could re­sult in less ac­cu­rate pay­ments.

The av­er­age Medi­care pay­ment for hip and knee pro­ce­dures, which are the most com­mon re­ceived by Medi­care ben­e­fi­cia­ries, ranges from $16,500 to $33,000, ac­cord­ing to the CMS. In 2014, lower-ex­trem­ity joint re­place­ments cost Medi­care more than $7 bil­lion for hos­pi­tal­iza­tions alone.

Most com­ments asked to de­lay im­ple­men­ta­tion of the model un­til Jan. 1, 2017.

The Mayo Clinic pointed out that more time is needed to fully un­der­stand and im­ple­ment the rule re­quire­ments and ed­u­cate staff and ben­e­fi­cia­ries.

Providers also ques­tioned the CMS’ de­ci­sion to ap­point each hos­pi­tal the sole bearer of risk in an ef­fort to study how they han­dle the fi­nan­cial con­se­quences and gains. Spread­ing the risk among physi­cians and post-acute care and skilled-nurs­ing fa­cil­i­ties would em­power them to dic­tate pa­tient care and al­low them to reap any fi­nan­cial re­wards should they meet met­rics un­der the pro­gram, the com­ments said.

Providers ar­gue that the de­ci­sion to ex­clude those providers could hurt the ini­tia­tive.

Another key to the model’s suc­cess is grant­ing hos­pi­tals waivers to al­low them to op­er­ate out­side of fed­eral kick­back and physi­cian self-re­fer­ral laws.

The laws pro­hibit physi­cians from mak­ing re­fer­rals for ser­vices cov­ered by gov­ern­ment pro­grams to en­ti­ties in which they have fi­nan­cial in­ter­ests un­less they meet cer­tain ex­cep­tions.

Waivers to the laws of­fer providers flex­i­bil­ity to en­ter into co­or­di­nated-care part­ner­ships.

A sim­i­lar per­mis­sion has al­ready been granted to Medi­care ac­count­able care or­ga­ni­za­tions.

The CMS likely will grant these pro­tec­tions be­cause it wants this model to suc­ceed, said Seth Lundy, a part­ner in the Washington, D.C., of­fice of King & Spald­ing.

A fi­nal rule is ex­pected by Novem­ber.

AMER­I­CAN AS­SO­CI­A­TION OF ORTHOPAEDIC SUR­GEONS: That will force many sur­geons and fa­cil­i­ties (with­out) fa­mil­iar­ity, ex­pe­ri­ence, or proper in­fra­struc­ture to sup­port care re­design ef­forts into a bun­dled pay­ment sys­tem.

TENET HEALTHCARE: Hos­pi­tals ad­ja­cent to the se­lected (ar­eas) will be faced with dif­fer­ent rules for physi­cian and pa­tient en­gage­ment that will place them at a com­pet­i­tive disad­van­tage.

THE FED­ER­A­TION OF AMER­I­CAN HOS­PI­TALS: No­tably, nowhere does the law ex­pressly state that CMS can make mod­els manda­tory. There should be no mis­take about what is hap­pen­ing here—(this model) rep­re­sents a ma­jor change in Medi­care pay­ment pol­icy.

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