Beginning in 2018, the Centers for Medicare & Medicaid Services (CMS) introduced a voluntary episode-based payment model, known as Bundled Payments for Care Improvement Advanced (BPCI Advanced). This model expands on the experience of the initial BPCI initiative, which started in 2013. The BPCI model successfully reduced Medicare payments, without adversely affecting complexity of cases nor mortality, for patients with joint replacement,1 though it did not seem to have the same effect for common medical conditions such as congestive heart failure (CHF), pneumonia, COPD, sepsis, and acute myocardial infarction.2
Despite these modest aggregate results for medical bundles across all participating programs, some positive outliers illustrate the potential for bundled payments. For example, Southwest General Hospital in Ohio showed significant improvements with CHF bundled payments. This 354-bed community hospital created a coordinated care model for all of its heart failure patients, beginning in 2015. According to an article in Modern Healthcare, this included “a year of intensive multidisciplinary meetings involving hospitalists, cardiologists, nurses, emergency department personnel, home health and emergency department staff, and leaders from local skilled-nursing facilities to get the program humming.”3 Multiple groups met regularly to improve processes, particularly for transitions in care. They focused on obtaining follow-up visits for CHF patients within 7 days of discharge from the hospital, and also invested in a nurse practitioner to coordinate the program, telehealth monitoring, intensified patient education, and a nurse transition coach that visited patients’ homes within 72 hours of discharge to provide education and support. Three years later, they reported that the program earned nearly $800,000 in savings payments from CMS, was associated with a 20% decline in 90-day CHF readmission rates, and a 30% improvement in patient satisfaction scores amongst these patients.3 They have also decreased the average skilled-nursing facility stay for their CHF patients by 8.5 days, moving from slightly above the national average to below it.
Despite the investments in care delivery, the benefits of decreased readmissions seems to have ultimately paid off for Southwest General. This example shows how a bundled payment program can incentivize hospitals to invest in new processes and services that improve care for patients, and that, unlike in a traditional fee-for-service model, will potentially result in return on investment through decreasing subsequent more costly health care utilization.
Under bundled payments, if health care providers manage resources and total costs efficiently – if they hold total costs below a pre-set target – they receive a portion of those savings. If they don’t, then they lose money. According to CMS, “a bundled payment also creates an incentive for providers and suppliers to coordinate and deliver care more efficiently because a single bundled payment will often cover services furnished by various health care providers in multiple care delivery settings.”4
BPCI Advanced is a single retrospective bundled payment for a 90-day clinical episode duration, meaning it is a fixed payment that covers the initial hospitalization (or outpatient procedure) and any care provided for the following 90 days.
The payment is tied to performance on specified quality measures
Five other quality measures only apply to selected conditions:
While BPCI Advanced is a voluntary payment program, it seems clear that payers are continuing to move toward promoting payment mechanisms that more closely incentivize value and coordinated care across care episodes and populations, rather than traditional, disconnected fee-for-service payment models.
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https://innovation.cms.gov/Files/x/bpciadvanced-whyparticipate.pdf
Select to expand. Save or download at:
https://innovation.cms.gov/Files/x/bpciadvanced-whyparticipate.pdf