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CMS’s Mandatory AMI Bundle Is Cause for Chest Pain

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This week the Centers for Medicare & Medicaid Services (CMS) announced a new mandatory bundled payment program for cardiac care. The proposed 5-year demonstration would go into effect on July 1, 2017, in 98 to-be-identified markets. The model would make hospitals financially accountable for the cost and quality of care for acute myocardial infarction (AMI) and coronary artery bypass graft (CABG) during inpatient stays and for 90 days following discharge.

Although Patrick Conway, M.D., and the Centers for Medicare & Medicaid Innovation Center (CMMI) deserve the equivalent of an Olympic gold medal for all the great work they have inspired in the area of payment reform, the announcement of a heart attack bundle is a dramatic departure from the well-studied elective procedure bundle. Whereas the evidence continues to mount in support of the efficacy of bundled payments for elective procedures, further study needs to occur for emergency procedures.

This past April saw the rollout of CMS’s first mandatory bundled payment program – the Comprehensive Care for Joint Replacement (CJR) initiative, which bundles costs for hip and knee replacements. Bundles for these joint procedures have been well studied. But bundling heart attacks is a very different exercise. Elective procedures are planned weeks ahead, enabling providers to predict and often avoid or minimize clinical variation.

Heart attacks, by contrast, are characterized by their unpredictability, their need for immediate treatment, and their high readmission rate – 20%. Ambulance drivers and EMTs are trained to take chest pain patients to the nearest ER, racing against the clock and doing everything in their power to keep the patient alive (or at the very least, to minimize heart muscle damage). There’s little chance that a patient suffering chest pains in the days or weeks following a cardiac procedure will be taken to the same hospital that performed that initial procedure.

As someone who has cared for these patients, I am completely supportive of Dr. Conway’s work. And chest pain procedures are expensive, so I understand CMS’s desire to find a way to make their treatment and payment more consistent. But this is still relatively new terrain. AMI patients have double-digit readmission rates and are at risk for dying or returning for a CABG procedure; the notion of generalizing findings from studies of elective procedures to this population is ridiculous.

Prior to today’s announcement, when asked about bundling AMI, my standard response has been “not in my top 100 conditions to bundle.” Should providers be accountable for cardiac care? Of course. But bundling emergent procedures warrants a well-conceived economic model to support the inherent complexity of this population.

The good news? As usual, there is a comment period.

Which many of us will exercise.

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