The CMS has delayed the expansion of a major bundled payment pilot, Comprehensive Care for Joint Replacement, and the implementation of its bundled payment initiatives for cardiac care from July 1 to Oct. 1, 2017, according to an interim final rule posted to the Federal Register. It also delayed, for a second time, the effective date of a final rule laying out the implementation of CJR and other bundled payment programs, from March 21 to May 20, 2017.

The agency also delayed its Cardiac Rehabilitation Incentive Payment Model and is also weighing pushing back implementation of all bundled payment initiatives even further, until 2018.

The Trump administration’s move to delay these initiatives raises questions about the future of government initiatives to usher healthcare out of fee-for-service operations and into a new age of value-based payment. Such efforts were a hallmark of healthcare reform under the Obama administration, which set the goal of having half of traditional Medicare dollars go through alternative payment models by 2018.

“This additional 3-month delay is necessary to allow time for additional review, to ensure that the agency has adequate time to undertake notice and comment rulemaking to modify the policy if modifications are warranted, and to ensure that in such a case participants have a clear understanding of the governing rules and are not required to take needless compliance steps,” the interim rule said.

It added that the delay would give participants more time to prepare for these models and that it would be preferable for payment periods to align with the calendar year. As a result, the CMS said, it is seeking comment on the possibility of delaying the start of cardiac bundles until Jan. 1, 2018. If it pushes the cardiac bundles to a later date, it would also delay the CJR expansion to the same date, it added.

In the CJR program, which rolled out in April 2016 across 800 hospitals in 67 metropolitan areas, Medicare pays providers a single amount to cover all the costs associated with a hip or knee replacement over a 90-day period. The program was slated to expand in July to include repairing hip and femur fractures as well as cardiac care.

The cardiac bundles, a five-year demonstration, would have applied to hospitals in 98 metropolitan areas of the U.S., holding them financially accountable for the costs of all care involved in bypass surgery and heart attacks. They were originally slated to begin in July and end Dec. 31, 2021.

The final rule whose implementation was delayed from March until May would in part have selected the applicable metropolitan areas for the cardiac bundles.

The CMS is seeking comment on “the appropriateness of this delay,” for 30 days after the interim final rule is filed for public inspection—slated for March 21—in the Federal Register, it said.

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