Cardiologists scramble to prepare for mandatory heart failure payment model
More than 2,600 cardiologists were surprised to find their names on a list that puts them under additional scrutiny from the U.S. government and will be tracking how well they can keep heart failure patients out of the hospital. Some of these clinicians are concerned about being required to meet the new quality care criteria starting Jan. 1, 2027, under the mandatory Ambulatory Specialty Model (ASM).
The stakes are high because payment adjustments tied to performance will begin in 2029; that means these data could go on to significantly affect physician reimbursement.
“The payment adjustment is real. The payment adjustment could be positive, up to 9%, or graded down to negative 9% of all of your Part B claims. That’s some serious money we’re talking about here,” explained Samuel Jones, MD, a member of the American College of Cardiology (ACC) Board of Trustees, past chair of the ACC Health Affairs Committee and director of inpatient electrophysiology at Memorial Hospital, Chattanooga Heart Institute, in the above video interview with Cardiovascular Business.
The Centers for Medicare and Medicaid Services (CMS) released the participant list for his new ASM in March. The goal, according to CMS, is to improve outcomes and reduce costs for high-expense chronic diseases. Heart failure and lower back pain were selected as the first conditions included in the model because of their significant impact on healthcare spending.
Unlike previous voluntary CMS demonstration programs, participation in the ASM will be required for selected physicians practicing in designated geographic areas. The program is scheduled to run for five performance years through Dec. 31, 2031.
“This is going to be a mandatory model,” Jones explained. “Our members may find that they are on a list that they were not aware they were on."
CMS said the model is intended to encourage earlier intervention and better outpatient management in order to reduce avoidable hospitalizations and unnecessary procedures. Heart failure care remains one of the largest drivers of Medicare spending; it currently costs the U.S. healthcare system an estimated $179.5 billion annually.
Under this new ASM, physicians will be evaluated using both quality and cost measures. Jones said CMS is still finalizing the details, but several metrics have already been outlined. These include rates of unplanned hospitalizations for heart failure and whether patients with reduced ejection fraction are receiving guideline-directed therapies such as beta blockers, ACE inhibitors and related medications.
The model also includes patient-reported outcome measures, something many cardiologists may not yet be prepared to track. This could be the Kansas City Cardiomyopathy questionnaire or Minnesota Living With Heart Failure questionnaire.
“Providers that are on that list need to make sure they have access to those because you have to go get a license ahead of time," Jones said.
In addition to quality metrics, CMS will evaluate physicians based on total heart failure-related spending attributed to their patients. Jones said that could include emergency department visits, hospitalizations and costly medications, even when those services occur outside the cardiologist’s direct control.
“A cardiologist who’s in bed at 2 a.m. and the patient is off in another state in the ER, that cost could be attributed to them if it’s for heart failure,” he explained.
Risk adjustment and regional fairness are also major concerns. Jones questioned how CMS plans to fairly compare physicians practicing in very different patient populations and healthcare environments.
“How do you make sure that this cardiologist can actually be compared to this cardiologist in a fair fashion?” he asked. “How do you make sure that those costs are appropriately attributed to them?”
Jones also noted that cardiac care is typically delivered by multidisciplinary teams that include nurse practitioners, physician assistants and subspecialists, but the ASM places accountability primarily on the individual general cardiologist.
“We know that cardiology is a team sport,” Jones said. “That’s not how they’re looking at it because they are assigning it just to the cardiologist.”
Although CMS intended the program to focus mainly on general cardiologists, Jones said some interventional cardiologists and electrophysiologists have appeared on the participant lists due to coding or classification issues.
“What we have found out in looking at the list, there are some cardiologists that are interventional cardiologists that are on the list that according to CMS should not be,” he said.
Jones urged cardiology practices to begin preparing immediately by identifying which physicians are included and analyzing their current quality and cost data. He said organizations already participating in accountable care organizations may have access to “shadow bundle” data that could help them understand future financial risks.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: [email protected]