CMS Brings Much-Needed Changes to Rules on TAVRs and Cardiac Rehab in BPCI Advanced

When 2020 begins, the BPCI Advanced Program from the Centers for Medicare & Medicaid Services (CMS) will enter the third of its six Model Years. For Model Year 3 (MY3), a new cohort will join the 1,300 providers currently enrolled in the program, and some recently announced program updates will bring more incentives and value to all participants – particularly cardiologists.    

TAVR splits from PCI 

Eleven of the 37 clinical episodes slated for MY3 involve cardiologists, which is an indication that CMS recognizes cardiology’s ability to lead the way in value-based payment programs. One of those bundles, transcatheter aortic valve replacement (TAVR), is a new addition to the program that comes at the request of providers.

Last week, CMS announced via email that not only will TAVR be its own bundle, it will now include an override mechanism that will split expensive TAVR readmissions from percutaneous coronary intervention (PCI) episodes. Starting with MY3, if a TAVR occurs after a PCI procedure, the PCI bundle will be canceled and the TAVR bundle will be triggered with separate episode pricing.

We are proud to have a collaborated with CMS on making this change. The CMS Innovation Center team noted that we were the first to bring the need for modifying the PCI bundle definition to their attention.

In early program performance, PCI emerged as a popular bundle in BPCI Advanced, with providers often succeeding in improving outcomes and earning savings by beating their target price. However, with the average outpatient PCI target price among Archway provider partners ranging from $15k - $20k, the average inpatent PCI target price ranging from $30k - $40k, and the average TAVR procedure costing more than $41k, the inclusion of spending associated with planned, clinically appropriate TAVR “readmissions” created a disincentive to provide clinically appropriate care and a significant barrier to success for PCI participants.

Archway’s value-based care team brought the data to CMS to advocate for amending the PCI volume. We’re encouraged to see CMS take the feedback and implement this change, and we are confident that the update will enable cardiologists to manage both PCI and TAVR episodes to the highest quality.

Cardiac rehab no longer a drag

CMS also announced last week that it will exclude the cost of cardiac rehabilitation (home-based, long-term care) and intensive (hospital-based) rehabilitation from cardiac episode bundle pricing in MY3. The expensive rehab costs – often a necessary solution for patients – previously led to ballooned total episode costs, causing providers to miss out on savings and even sometimes have to pay CMS back.

Studies have shown that cardiac rehabilitation facilitates better overall outcomes that can have lasting effects over a couple of years. Yet the difficulties in meeting pricing targets as a result of cardiac rehab’s role in episode bundle pricing (unintentionally) was disincentivizing providers from prescribing this path of care for patients whose condition clinically warranted cardiac rehabilitation. This is another development that we think will enable better care outcomes and an improved provider experience as well.

CMS listens to stakeholders

These changes in BPCI Advanced reward cardiology providers for making the best decisions for patients. We commend CMS for better aligning financial incentives with improved care, and we are proud to have advocated to CMS for both of these changes.

CMS following through with these episode updates demonstrates the agency’s commitment to ongoing improvements of value-based payment programs and collaboration with stakeholders. We encourage all providers in value-based payment programs to speak up when you find areas for improvement in the program. Chances are you’re not the only one, and you could be a catalyst for meaningful change.

To precisely manage cardiac episodes, manage CMS data, and predict NPRA payments, request a demo of our SaaS solution.