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.