10.Care Redesign Case: Center for Medicare and Medicaid Innovation Center

MODULE 9 | Section 10 of 12

Care Redesign Case: Center for Medicare and Medicaid Innovation Center

CENTERS FOR MEDICARE & MEDICAID SERVICES BUNDLED PAYMENTS FOR CARE IMPROVEMENT

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.

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HEALTH CARE PROVIDERS CAN VOLUNTARILY OPT TO PARTICIPATE IN BPCI ADVANCED FOR ANY OF THE 32 SPECIFIED CLINICAL EPISODES:
  • Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis
  • Acute myocardial infarction
  • Back & neck except spinal fusion
  • Cardiac arrhythmia
  • Cardiac defibrillator
  • Cardiac valve
  • Cellulitis
  • Cervical spinal fusion
  • COPD, bronchitis, asthma
  • Combined anterior posterior spinal fusion
  • Congestive heart failure
  • Coronary artery bypass graft
  • Double joint replacement of the lower extremity
  • Fractures of the femur and hip or pelvis
  • Gastrointestinal hemorrhage
  • Gastrointestinal obstruction
  • Hip & femur procedures except major joint
  • Lower extremity/humerus procedure except hip, foot, femur
  • Major bowel procedure
  • Major joint replacement of the lower extremity
  • Major joint replacement of the upper extremity
  • Pacemaker
  • Percutaneous coronary intervention
  • Renal failure
  • Sepsis
  • Simple pneumonia and respiratory infections
  • Spinal fusion (non-cervical)
  • Stroke
  • Urinary tract infection
Percutaneous Coronary Intervention (PCI) Cardiac Defibrillator Back & Neck except Spinal Fusion

The payment is tied to performance on specified quality measures

    • all-cause hospital readmission measure, and
    • advance care plan is required for all clinical episodes.

 

Five other quality measures only apply to selected conditions:

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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.

Check out more information and resources from the

BCPI Advanced Program

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REFERENCES

  1. 1-Dummit LA, Kahvecioglu D, Marrufo G, et al. Association between hospital participation in a Medicare bundled payment initiative and payments and quality outcomes for lower extremity joint replacement episodesJAMA.

 

  1. 2-Joynt Maddox KE, Orav EJ, Zheng J, Epstein AM. Evaluation of Medicare’s bundled payments initiative for medical conditionsN Engl J Med. 2018:379(3):260-269.

 

  1. 3-Meyer H. Hospital’s experience with heart-failure bundles could be blueprint for othersModern Healthcare. 2018.

 

  1. 4-Centers for Medicare & Medicaid Services. BCPI Advanced. CMS website. Updated September 2018. Accessed September 2018.

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