Medicare’s proposed Cardiac Rehab Incentive Payment Model: The potential to make a difference

In a recent article, Laurie Leonard, Consulting Director at Schumacher Clinical Partners explains the potential to make a difference in Medicare's proposed Cardiac Rehab Incentive Payment Model.

This summer, the CMS proposed yet another bill advancing the nation's march toward value-based care delivery. In addition to expanding bundled payments to include hip and femur fractures, the proposal creates episodic payment models for heart attack hospitalizations and cardiac bypass surgery. The industry has expected that cardiac procedures would be next in the expansion of bundled payment models, so that's no surprise. But there is one provision in the proposed bill that isn't getting a lot of attention yet and which could potentially deliver significant upside: the Cardiac Rehab Incentive Payment Model.

The Cardiac Rehab Incentive Payment Model

The proposed provision establishes incentive payments to participating hospitals for cardiac rehab services received by their patients discharged from a hospital stay for a heart attack (AMI) or cardiac bypass surgery (CABG). Hospitals would use this incentive payment "to coordinate cardiac rehabilitation and support beneficiary adherence to the cardiac rehabilitation treatment plan to improve cardiovascular fitness." The incentive payments have two tiers:

$25 per cardiac rehabilitation service for each of the first 11 services during the care period for a heart attack or bypass surgery.
$175 per service provided after the initial 11 services, up to 36 services (up to 72 if an extension is granted or the patient requires intensive rehab)
The cardiac rehab (CR) incentive payment provision is noteworthy for a few reasons. For one thing, CMS is clearly attempting to increase utilization of CR services. CMS clearly believes that more rehab promotes value, and is not leaving it to chance that the physician will encourage its use absent such an incentive. Moreover, there is strong, well-established evidence of CR's clinical efficacy, including a decrease in mortality and survival rates, fewer cardiac events and reduced hospitalization. So why the need for additional incentive?

Despite overwhelming evidence of the efficacy of cardiac rehab, and coverage by the Medicare program, CMS reports that only 15% of patients actually participate in such a program. The reason appears to be two-fold:

1. Physicians don't refer their patients

2. Patients don't participate when they are referred

Neither of these reasons directly implicates the hospital. So will the incentives – paid to the hospital - be enough to achieve the intended outcomes? How do hospitals counter these forces so they can take advantage of the incentive payments?

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