The CMS’ late delivery of performance results and the Thanksgiving calendar could reduce provider participation in Medicare’s largest bundled-payment demonstration program.
Hospitals and physician groups already participating in the Bundled Payment for Care Improvement Advanced program have until Dec. 1 to decide whether to shrink or expand the number of conditions for which they’ll receive fixed payments covering the entire episode of care. Providers wanting to join the program face the same deadline for selecting from 33 inpatient and four outpatient conditions.
The CMS said this will be the last opportunity for episode selection and new participation before the five-year demonstration ends in 2023.
The agency in early October released provisional target prices for each clinical episode for 2020, allowing providers to begin evaluating which episodes look financially attractive. The targets for certain episodes, such as outpatient angioplasty with stent, seem especially appealing, experts say.
“The target for outpatient stents is so advantageous that you wouldn’t have to create any clinical change to make money,” said Jonathan Pearce, a principal at Singletrack Analytics.
But as of last week, providers still had not received their reconciliation results for the past year, which is key information for deciding on future participation. Those results also determine their actual target prices.
Some agency watchers are hoping the CMS either delays the Dec. 1 decision date or gives providers a chance to drop out later. BPCI Advanced participation fell to 1,086 hospitals and medical groups in March, down from 1,299 organizations when the program began.
“The number of (organizations) coming in is not as many as initially hoped,” said Kathryn Hayes-Hallowell, a principal in strategy and innovation at Premier, which advises more than 50 BPCI Advanced clients. “The Dec. 1 timeline is a little bit of a challenge for participants, because they’d like to have an actual approved (price target) as they decide how much deeper they want to go.”
Northwestern Medicine currently is undecided whether to continue participating in three episodes—chronic heart failure, sepsis, and hip and knee replacement, said Jessica Walradt, manager of value-based care at the Chicago-based hospital system. She predicted some providers will likely opt out of the program given the dearth of data coming from the CMS.
The CMS did not respond to a question about when it would release the reconciliation data.
Under BPCI Advanced, the CMS pays a fixed price for each episode, which starts with an initial hospital admission or outpatient procedure and includes almost all services during the next 90 days. Providers make money if they keep total costs below the target price, which the CMS has discounted by 3%. They’re at risk for up to 20% of costs that exceed the target price. Savings payments are adjusted based on performance on seven quality measures.
The program, started in October 2018, is widely seen as one of the most promising approaches to accelerating the nation’s transition to value-based payment. Experts hope it will encourage more provider groups to take on bundles for complex medical conditions like congestive heart failure, chronic obstructive pulmonary disease, and sepsis, for which multiple hospitalizations and emergency department visits are common.
Up to now, providers largely have chosen procedural bundles such as joint replacements, where it’s easier to redesign care to achieve cost and quality improvements. But waste has already been squeezed out for those episodes, experts say.
For UMass Memorial Healthcare, expanding its participation from just joint replacements to medical bundles like COPD, heart failure, stroke and sepsis could build on investments in care managers and post-acute staff for its Medicare ACO, delivering savings on high-cost patients, said Jeanne Shirshac, vice president of health policy.
But succeeding with bundled payment for these episodes is hard, she added, because patients with these conditions need to be identified and managed quickly.
Shirshac will be meeting with her clinical teams over the next few weeks to decide whether to move forward on new bundled episodes. “Bundles are a win all around, for the hospital system, for the patient, and for the doctors,” she said. “But we’re not sure yet. We’re a little risk averse.”
