CMS Proposes Cancellation of Episode Payment Models, Cardiac Rehab Incentive Model The Centers for Medicare and Medicaid Services (CMS) last month issued a proposed rule canceling its episode payment models (EPMs) and the cardiac rehabilitation incentive model, which were slated to start on Jan. 1, 2018. The agency also made significant changes to its joint replacement payment model, reducing the number of mandatory geographic areas participating and allowing participation in the remaining areas to be voluntary. “Changing the scope of these models allows CMS to test and evaluate improvements in care processes that will improve quality, reduce costs, and ease burdens on hospitals,” said CMS Administrator Seema Verma. “Stakeholders have asked for more input on the design of these models. These changes make this possible and give CMS maximum flexibility to test other episode-based models that will bring about innovation and provide better care for Medicare beneficiaries.” CMS had selected 1,120 hospitals to participate in the EPMs for acute myocardial infarction (AMI) (triggered by admissions for AMI and admissions representing percutaneous coronary intervention treatment for AMI) and coronary artery bypass for acute care hospitals. Additionally, 1,320 hospitals had been selected to participate in the Cardiac Rehabilitation Incentive Payment Model, which would have allowed for a retrospective payment based on total cardiac rehab use of beneficiaries attributable to participant hospitals. Cancellation of the program will impact eligible clinicians, including physicians and non-physician practitioners, who were planning to use participation in the EPMs to qualify as participating in Advanced Alternative Payment Models (APMs) outlined under the Quality Payment Program, particularly in this first year. ACC Advocacy staff and leaders are reviewing the update now and more information on the impacts to cardiovascular clinicians and next steps will be posted to ACC.org and included in the Advocate. Moving forward, CMS notes plans to increase opportunities for providers to participate in voluntary initiatives rather than large mandatory episode payment model efforts. “The ACC will continue to work with CMS on opportunities for clinicians to participate meaningfully in Advanced APMs,” said ACC President Mary Norine Walsh, MD, FACC. “As we move from volume-based care to value-based care, the path forward is challenging and we must work together to find solutions.” ICD Registry a Model for Quality Improvement The ACC’s ICD Registry, one of the College’s 10 NCDR registries, “has been a model of professional transparency, accountability, and science in exchange for expanded payment for devices” since its creation as a means for hospitals to meet the Centers for Medicare and Medicaid Services (CMS) requirement that patients receiving ICDs for primary prevention be enrolled in either an approved clinical trial or in a national registry, write Frederick M. Masoudi, MD, FACC, and William J. Oetgen, MD, FACC, in a recent leadership page published in the Journal of the American College of Cardiology. To date, more than 1.7 million ICD implantations have been recorded in the ICD Registry, and more than 75 peer-reviewed scientific papers using ICD Registry data have been published. “These studies have advanced our understanding of device selection, care, and outcomes nationally, addressing key questions of the effectiveness, safety, equity, and efficiency of care,” note Masoudi and Oetgen. “These studies have exponentially increased the value of the ICD Registry data well beyond the specific issues outlined in the original CED; their validity has been substantially enhanced with the availability of a true national denominator of patients receiving this therapy.” With CMS re-evaluating the registry mandate, Masoudi and Oetgen stress that the benefits of the registry must be considered. “Given that the indications for ICD therapy will change with this update, patients, physicians and policymakers will need valid contemporary data to ensure the optimal use of these devices and to achieve better outcomes,” they write. To date, more than 1.7 million ICD implantations have been recorded in the ICD Registry, and more than 75 peer-reviewed scientific papers using ICD Registry data have been published. Scan the QR code to read the full article. Million Hearts Celebrates Success, Sets New Goals for 2022 Between 2012 and 2016 the Million Hearts program brought together 120 official partners (including the ACC), 20 federal agencies, and all 50 states and the District of Columbia around the shared goal of preventing one million deaths from cardiovascular disease over a five-year period. In its recently published “Meaningful Progress 2012-2016: A Final Report,” early data shows that the novel public/private initiative has helped prevent an estimated half a million cardiovascular events, while also making significant headway in reducing cardiovascular risk factors like smoking and hypertension. Co-led by the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS), Million Hearts is focused on keeping people healthy and optimizing quality care through its ABCS approach: Aspirin when appropriate, Blood pressure control, Cholesterol management and Smoking cessation. Among the patient-focused goals, Million Hearts saw substantial reductions in its initial five years in tobacco use, improving cardiovascular health for millions, including those experiencing secondhand smoke. In fact, the initiative estimates it will surpass its target (reduce tobacco use by 23.6 percent) by the end of 2017. Among the health care system-focused goals, CMS Electronic Health Record (EHR) Incentive Programs helped identify half a million patients with hypertension through a 53 percent increase in EHR use in outpatient care between 2011 and 2015 (from 34 percent to 87 percent). The Million Hearts report also highlights two specific programs for notable achievements over the past five years: Million Hearts Hypertension Control Challenge and Million Hearts Cardiovascular Disease Risk Reduction Model. The competition recognized 59 doctors, health care practices and health systems, including ACC members and medical groups reporting via the CMS Group Practice Reporting Option, for achieving blood pressure control rates at or above 70 percent for more than 13.8 million patients. Meanwhile, 516 organizations across 47 states, the District of Columbia and Puerto Rico now use the Risk Reduction Model, which tests how financial incentives impact the identification and management of risk for cardiovascular disease among eligible Medicare beneficiaries. To assist practices participating in the Risk Reduction Model, the ACC partnered with CMS and the American Heart Association (AHA) on a risk assessment tool to help predict the 10-year risk of developing atherosclerotic cardiovascular disease (ASCVD). The Million Hearts Model Longitudinal ASCVD Risk Assessment tool launched in November 2016 as an extension of the ASCVD Pooled Cohort Equation, which was first published in the 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk. “Progress was clearly made in improving CV care and health by more than 120 partners, including ACC and its members, during the first five-year phase of Million Hearts. However, the pace of improvement is far too slow and the cumulative effect of decades of obesity, physical inactivity and diabetes threatens further progress in cardiovascular disease prevention,” states Janet Wright, MD, FACC, executive director of Million Hearts. For example, while the Million Hearts Hypertension Control Challenge demonstrates that the initiative’s target blood pressure control target is achievable, overall blood pressure control has only increased by 4.3 percent between 2009-2010 and 2015-2016 (53.4 percent vs. 57.7 percent) across the U.S. Looking ahead, Million Hearts 2022 will continue to improve its ABCS approach, focusing primarily on decreasing sodium intake, while increasing physical activity. New efforts for Million Hearts 2022 will focus on prioritizing improvement outcomes for highly affected populations, particularly African-Americans and Hispanics between the ages of 35 and 64. “With a strong foundation of powerful private and public sector partners, Million Hearts 2022 is designed to accelerate the implementation of strategies that work to prevent cardiovascular disease and improve heart and brain health. We look forward to working with the College and all members of the cardiovascular team to get to at least a million by 2022,” says Wright. The ACC worked closely with Million Hearts over the last five years to assist with achieving its goals of improving performance in cardiovascular disease prevention. The ACC, through its registries like the PINNACLE Registry, CardioSmart patient portal, live education programs and other outlets, helped to share Million Hearts messaging around prioritizing the ABCS system, harnessing the power of health information technology to improve health outcomes, and participating in new models of care that recognize and reward outcomes and value. These efforts will only continue as Million Hearts looks ahead to 2022. Scan the QR code to read the full Million Hearts report. Advocacy 101 for FITs: A Conversation with Thad Waites, MD, FACC Aaron Kithcart, MD, PhD, and Sandeep Krishnan, MD, talked with Thad Waites, MD, FACC, chair of ACC’s Health Affairs Committee (HAC) and a leading voice in the ACC, to get his thoughts on advocacy and learn about his journey to becoming an advocate for the ACC. How did you first become involved in advocacy? My first advocacy effort was through the American Legion Boys State in Mississippi just before my senior year in high school. I was elected to be Superintendent of Education for the state for a day. My parents were teachers and my father had run for superintendent of our county school district, so advocacy was a natural part of my life from a young age. I then had a long hiatus from advocacy during my medical training, military tenure and very busy clinical practice. My election as governor of the ACC Mississippi Chapter signaled my return to advocacy. In that role, I learned more about advocacy at the state and national levels. Then, as chair of ACC’s Board of Governors (BOG), my involvement and study of the political process grew exponentially. As a past chair of the BOG, I was ex-officio on the Advocacy (now Health Affairs) Committee and found myself hooked on the exciting world of advocacy. Since then, I’ve been chair of the HAC and worked very closely with our ACC staff – the best advocacy staff I’ve worked with in any association. Why should Fellows in Training (FITs) get involved in advocacy? I’ll answer by asking if the following affect FITs and their budding careers: the Affordable Care Act, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), relative value units, electronic health records, maintenance of certification and the appropriate use criteria or Advanced Imaging Mandate, among others that could encroach upon the sacred interaction between patient and physician. Since “yes” is the answer, I encourage FITs to be fully involved. It is our First Amendment right and responsibility to speak out and we must. How can FITs become engaged in the advocacy process? Attend the annual ACC Legislative Conference held every September in Washington, DC! At the conference, FITs can network, learn about advocacy and visit Capitol Hill. Travel grants may be available through the state chapter and national office to fund your trip. Get involved with your state chapter and reach out to the ACC staff who focus on state advocacy. Within the nominating process during the fall, apply for any of the numerous positions within the ACC that include advocacy needs. This would include all member sections, various work groups and task forces, and steering committees of the councils. Apply for the Emerging Advocates Program, which provides advocacy education to a small group of ACC members who do not have previous advocacy experience. Also, apply for the HAC itself; we currently have two FITs, as well as an Early Career member, amongst our ranks. From an advocacy standpoint, what do you worry about? We have a very complex legislative process. And, our very complex health care system was built over the years by the accretion of more and more regulation and complexity. I would like our country to have the best health care system possible: a system that achieves the ACC’s triple aim of lowering costs, improving outcomes and improving the health of the populace. This will be difficult but we will never achieve it without constant advocacy for our patients. Is there anything that FITs should do to get ready for MACRA implementation? MACRA and its Quality Payment Program is the law and repeal is not on the agenda. It was passed by a very strong bipartisan vote and its supporters are largely still in Congress. The basis of MACRA is a transition from volume to value that the ACC has advocated for over several years. Yet, whether we got more complexity than we bargained for is another consideration. Implementing MACRA is a team effort. FITs should know, within their individual systems, whether they will be scored in the Merit-based Incentive Payment System or in an Alternative Payment Model and adjust their daily work accordingly. And, FITs should learn as much as possible about MACRA and what their hospitals and institutions are doing to get ready. A valuable resource is the MACRA Hub: ACC.org/MACRA. ACC Comments on Proposed Medicare Physician Fee Schedule The ACC this month submitted comments to the Centers for Medicare and Medicaid Services (CMS) in response to the proposed 2018 Medicare Physician Fee Schedule and related policies included in the proposed rule. The ACC’s comment letter specifically addresses proposed changes to the new appropriate use criteria (AUC) requirement for advanced imaging services (i.e., SPECT MPI, CT and MR), as well as changes to malpractice and practice expense components of the fee schedule, and recommendations regarding work relative value units for specific codes, payment rates for services provided by off-campus provider-based departments, quality and value program adjustments and reporting, and patient relationship codes to be used in quality reporting. The comments also touch on the implementation of new patient relationship codes aimed at improving cost measurement attribution. Read the comments on ACC.org. The final Medicare Physician Fee Schedule is expected later this fall.
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