Calls mount for CMS to address problem of patient overlap across payment models

BJC HealthCare is in the CMS’ flagship accountable care organization program and nine of its hospitals participate in the federal agency’s flagship bundled-payments program.

Recently, the St. Louis-based not-for-profit health system learned that quite a few patients it treats under bundles are also attributed to its ACO.

Before knowing that, it was tough to predict how much savings the bundles would generate, said Dr. Sheyda Namazie-Kummer, director of the clinical advisory group in BJC’s Center for Clinical Excellence.

“It also made it difficult for us to understand how many resources we would put in place to have to manage this patient population, because we didn’t know who exactly that patient population was,” she said.

The problem of overlap in the CMS’ various payment initiatives, including ACOs and bundled-payment programs, can introduce confusion and frustration when it comes to determining which program gets credit for those patients’ care. The CMS wants to avoid double-rewarding for savings on an individual patient’s care, such as if the patient is in an ACO and received qualifying care from a Bundled Payments for Care Improvement Advanced provider. So when it comes down to reconciling who is credited for the savings, things get tricky. And they’re bound to get even more complicated as the CMS adds alternative payment models to the mix.

“This is one of the top one or two issues on the minds of any participant in any of these models,” said David Ault, counsel with Faegre Baker Daniels and a former division director with the CMS Center for Medicare & Medicaid Innovation.

New research highlights just how sweeping the problem is. More than 1 in every 4 patients receiving care under the CMS’ flagship bundled-payments program, the Bundled Payments for Care Improvement initiative, were also attributed to its flagship ACO program, the Medicare Shared Savings Program, in 2016, according to an August study in the Journal of Hospital Medicine. Conversely, 1 in every 10 MSSP patients received care at a BPCI participating hospital in 2016.

“As policymakers really think about, ‘How do we take value-based reform to the next level?’ this issue of payment model overlap is critical to that,” said Dr. Joshua Liao, medical director of payment strategy at UW Medicine in Seattle and an author of the study.

Liao said the true overlap is likely bigger than the study captured, as it didn’t look at other initiatives like the CMS’ Comprehensive Care Joint Replacement Model or the Next Generation ACO Model. The data was also collected prior to the rollout of BPCI’s successor, BPCI Advanced, in October 2018.

New models coming out, like CMS’ Primary Care First and Direct Contracting, add to the need for a solution, he said.

The CMS so far has approached the issue on a one-off basis as it releases new models, Ault said. What’s truly needed, Ault and others watching the issue said, is an overarching policy that governs all initiatives.

“CMS recognizes this is an issue that needs to be addressed,” he said. “It’s just a difficult problem to solve.”

The CMS attempted to clarify things in June when it announced that starting in 2020, providers participating in BPCI Advanced will take precedence over all MSSP beneficiaries—meaning, their savings will be carved out from the ACO’s savings. Currently, this is only the case for certain MSSP beneficiaries, those categorized under the program’s basic track.

In a statement, the agency said the updated overlap policy gives providers the flexibility to participate in multiple value-based care initiatives while reducing beneficiary confusion.

MSSP ACOs finish their reconciliation—or determination of what savings or penalties are owed for a given year—well before that of BPCI Advanced participants. To ensure the CMS doesn’t pay double rewards in cases of beneficiary overlap, BPCI Advanced providers calculate their savings after the ACO savings have been reconciled and carve those out from the ACO savings.

On a practical level, the June announcement means if John Doe is a patient in an MSSP ACO, and is admitted to a BPCI Advanced hospital with a clinical episode, such as congestive heart failure, that episode of care will be attributed to the BPCI Advanced provider, said Gina Bruno, vice president of value-based care with naviHealth.

The CMS is also trying to calculate a way to compensate aligned ACOs for their contributions to those patients’ care, Bruno said. “ACOs, especially those that work with BPCI Advanced providers will say, ‘Well, wait a minute. John Doe has been our patient for a period of time. We have a team that follows up with him. We play a part in managing his chronic disease. How do we get credit for our contributions to his outcomes?’ ”

Therein lies the trickiness of overlap. Experts say providers who contributed to a patient’s care often wind up feeling as though they didn’t get the commensurate reward.

“There is a risk of expending resources to support patients who ultimately are not attributed to the model to which that operating expense was aligned,” Bruno said.

For 15-hospital BJC, CMS’ June announcement solved the overlap problem, since those are the only CMS programs in which the not-for-profit health system experiences overlap, Namazie-Kummer said.

While there is a lot of overlap across Livonia, Mich.-based Trinity Health’s ACOs and bundled-payment programs, it hasn’t been a problem since the health system participates in both types of programs in each of its markets, said Emily Brower, Trinity’s senior vice president of clinical integration and physician services. Not only is Trinity in the MSSP and Next Generation ACO models, but it is involved in the BPCI Advanced and the CMS’ bundled-payment program for joint replacement.

“Since we are managing both, we don’t have as much difficulty trying to figure out which patient is in which and how the dollars flow,” Brower said.

However it would be challenging if a health system’s ACO patient had an episode of care managed by an outside bundled-payment provider.

“Those questions of overlap and exclusion are super important,” she said. “We really need to understand it. We need to have good insight and really, really clear guidance from CMS around how it flows.”

The National Association of ACOs, in a September 2017 letter to CMS Administrator Seema Verma, asked the agency to share data on Medicare ACO participants’ spending on bundled-payment patients on a quarterly and annual basis.

The letter said ACOs receive negative adjustments and miss their savings thresholds but don’t understand why. “This lack of transparency undermines the integrity of the program and if not fixed will lead to slower program growth at a minimum and may even lead to ACOs leaving the program,” the letter stated.

A NAACOS spokesman wrote in an email that the CMS has since shared some aggregate data.

BPCI Advanced has already been shedding participants, and Liao said he’s concerned that the problem of overlap could discourage provider participation in that and other payment models.

At least five CMS payment models could overlap with one another: MSSP, BPCI Advanced, CJR, the advanced primary-care medical home model Comprehensive Primary Care Plus and the Oncology Care Model, said David Muhlestein, chief research officer with Leavitt Partners.

“If everybody is getting credit for it, you could potentially pay the same bonus payment five times,” he said. “Or if everybody does really poorly, all of them would pay the same penalty payment.”

There’s also a broader societal problem with overlap. It makes it difficult for the CMS Innovation Center to study whether its payment model experiments are actually saving money and improving patient outcomes. In that respect, the CMS is between a rock and a hard place, Muhlestein said.

“If they want to test many different programs to find out what works currently and not have overlap, you kind of can’t,” he said.