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Congress of the Muited States ‘Washington, DE 20515, September 21, 2015 Mr, Anarew Slavitt Patrick Conway, M.D., MSe Acting Administrator Deputy Administatr. Innovation & Quality Centers for Medicare & Medicaid Services Chier Medical Officer Hubert H. Humphrey Building Centers for Meicate & Medicaid Services 200 Indepenclence Avenue, SW 7500 Security Boulevant ‘Washington, D.C. 20201 Baltimore, MD 21244 Dear Mr, Slav and Dr. Conway: CMS recently proposed the Comprehensive Care for Joint Replacement Model (CCIR), a new episode-based payment model for lower extremity join replacement (LEJR) that would apply to 75, Metropolitan Statistical Areas (MSA’s) for five years. The CCR proposed payment model represents a significant change for beneficiaries and providers because it constitutes the first mandatory Medicare episode payment model promulgeted under CMS? CMMI authority. Other ‘CMS proposed models, including the Bundled Payments for Care Improvement (BPCI) on which the CCIR model was based, have all been voluntary. Given tis substantial change for Medicare beneficivies and providers, we raise certain questions and ask that you delay the implementation ‘of the CCIR payment model fr atleast one year. LIS has a goal of tying 85 percent of all traditional Medicare payments to quality or value by 2016 and 90 percent by 2018 through programs such as Hospital Value Based Purchasing. To be Sure, inereasing value by means of improved outcomes and reduced cost isa gol that we all share, ‘Asa result, the questions below relate not to the goa itself but, rather, how the Centers for ‘Medicare and Medicaid Services (CMS) seeks to achieve it 1, We recognize the uniquely postive i ence that patent choice has in achieving ‘quality, responsiveness, effectiveness, and efficiency of healthcare services. Systems ‘that foster patient choice have proven to work, whereas those that supplant patient choice with centralized contol have often le to shortages, atoning, and poor sutsomes. IF ultimately places post-acute caro (PAC) funding with hoepital contol, the CCIR model would likely ereate a strong incentive for hospitals to acquire post- cute care facilities and orthopedic surgery practices, or preclude independent practices rom performing surgeries at the hospital. There isa considerable body of evidence siggesting that healieare market consoldation ean have deleterious effects on patients, providers, and taxpayers. It also appears likely that hospitals would be compelled 0 ‘Between 1998 2012 the were 1113 merge acqistns involving lof 2277 hosp. Mages Fave neni dvbledn event es, Tete wee 9 agp merges in 2014, 98 2013, sn 95 bn 2012, Compare tat ih restit the provision of additional services by Mestcare beneficiaries’ physicians in ‘order to mitigate the sisk that hospitals wil face under the CCIR progssin. What safeguards are incorporated int the proposed CCIR model, end are under consideration in any possible futre iteration, that would guard against hospital-diven vertical integration or other forms of market consolidation that could lad to higher costs? Consequently, what protectins ae incorporated into the proposed CCIR model to ‘maintain a patient's freedom fo choose thei provider, course of treatment, and medical 2, Weare concemed that patients requiving higher-cost complex surgeries (such as hip fimotores and ankle replacement procedures) or who suffer from multiple chronic ‘onsitons may find it more difficult to find hospitals willing to serve them, since the ‘greater isk of complications o the higher level of post-aute care associated with ther condition would be logically viewed by hospitals as increasing their sk und the ‘proposed CCIR model. Additionally, since the CCJR model excludes “non-ceet jin replacement surgeries (many of which involve complex hip fractures) from its ‘quality framework, bo otherwise maintains such cases for “target price” and episode expenditure purposes, this could potentially place foo much emphasis on the cost of these vulnerable patients’ post-acute care without adequate consideration of their ‘outcomes and the quality of care they receive. What safeguards are incorporated into the ‘proposed CCIR model to ensure that patents with complex surgeries or chronic conditions would have access to the fll spectrum of hospitals, physicians, and post cite are providers under CCIR that they re able to access today? 3, Small and roel hospitals are a crucial resource for numerous communities. The risk placed on hospitals by CCIR, as well a the oversight and administrative responsibilities {hat hospitals would have to heer for 90 days post-discharge may be so burdensome that small al ral hospitals may have litle option other than to be subsumed into larger systems or efain fiom offering lower extremity joint replacement surges. What safeguards ae incorporated ito the proposed CCIR program to addess the specific needs and circumstances of sinall and rural hospitals? ‘reget n 2005, and 14 2006. Aneven Hospi Associon,Trenack Charo 2012: Tends Aig opiate ton, ir Sc also: Gen Malik nd te Kes, “The lef Malas Sytem on ep Pcs Jounal of Hah avo, Vol. 262007, yor 100-M3- Se sw. Ma apn "Wha ee Ken Abost Campetton ne uly at Core Mate?” Naciona Baceaof Bonomi Rescrch Warne Paper Ne (250, ex 2006, ip abo 201 pl 112005 ly aque pysican eel res wee one hospi 8 208, eer of ys actos ‘were spl one Carine Has, "More Delors iving Up uate Prato” The Me Yok Tes, Mach 25,2010 (Gevato House Conaites on Ways an Mea, ering on Hells Cae nds Cosaiinin, September 9, 2011 md Hose Commies on ial ashes, Ssbeories a ovesttions, Ores Replat, el Care ‘Redignet a gaa: The Dei of Sal nt Solo Med Pate” Duly 18,2012) Ti 204 te hae of cel n hove on emer stken th pie a tated tbe om o about ned aad ony 2 pent of ‘el Hote pyesane wee ssking slo patie Did Rost, “Hospi Nos Need a Mpporatie Oath” The New York Tey Nach 6,218 Sao as: Xu, Wu AM, Makry MA. The Potential Haars of Hostal Conon: Into for Quy, Aces end Pe. id, Polished ene Aga 13,2015 4. This CCIR model requires sophisticated coordination of ear that will demand ‘uditional providers within the past-acue setting to collaborate with hospitals to define ‘uid monitor patients cae plan? ‘The CCIR proposed rae indicates that forcing post: acute care providers to inves in Electronic Health Records (EHRs) will accomplish the ‘needed coordination, es hospitals that rely on post-acute care providers without EHRs ‘ay not be eligible for reeonelition payments in the future. How would this mandatory approach within the CCIR model prevent forced relationships between providers based ‘on the meaningfal use of BARS; rather than allowing these choices to be based on wo ‘provides th best quality of eae, keeps patients the saest, and does the best job of «coordinating with the hospital and other providers? 5. ‘The (tal amount of gsinshaving payments fora ealendar year paid to an individual physician, nonphysician practioner, or physician group practice who isa CCI collaborator cannot execed a cap equal to $0 percent of the total Medicare approved ‘amounts under the Physician Fee Schedule (PFS) fr services furnished to che putieipant hospital's CCIR benelcites during a CCIR episode by ha physician, now ner, or members of the physician group practice. Why are you ws aymens to providers who will be responsible for much ofthe his model? Additionally, why are post-acute care providers ‘not meaningfully ineluded inthe CCIR bundle to ensure quality care is provided over the entire continuum of eae? In light ofthe January 1, 2016 effective date proposed by the Agency, we request your response to these questions no later than October 1, 2015. The CMS proposal represents a significant change to our healtheare delivery system which could have negative impact on patient choice, acess an quality. Given the fact that the proposed rule will nt be finalized until almost the year’s end, it wll give physicians, hospitals and postacute providers litle or no time to prepare for this abrupt shift in payment for these high-volume procedures and the changes in care delivery ‘that chey will requie, Asa result, we as that you seriously reconsider the CCJR payment model Ata minimum, we ask that you delay the implementation ofthe CCIR payment model fora least one year. ‘Yours teuly, * Cuts esses htt wl ete shing rangers with ots cae providers Seep 1297 af he CNS popes CCH ae LW a Aixlae bibl ash /Soseph Hog, DO, Paul Gosar, DDS aD ~\ D)gioMe~ fae - Duncan wie Gohmest Dina Titws AND lo dk: Joh Fleming, Carlos Curbelo| ‘Steve Coben Bob Goodlatte ‘Bruce Westerman ry Bueshou, MD. David Soot Dn boright. Dan Benishek, MD. Teas Sowell

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