Hospital groups previously criticized the Medicare payment bundling program, and are worried CMS hasn’t released enough information to enable them to prepare.
Claims data analysis
Hospitals need to start by assessing their spending patterns and the regional benchmarks for the procedures included in TEAM, said Brian Fuller, managing director for value-based care design and delivery at the consulting firm ATI Advisory.
But CMS has not released the full Medicare claims data hospitals need, Fuller said.
CMS plans to provide baseline claims data to TEAM participants next year, an agency spokesperson wrote in an email. "The CMS Innovation Center recognizes how helpful data can be as hospitals prepare for model implementation and is working to provide it in a timely manner," the spokesperson wrote.
There are workarounds. Consultants and research institutions have access to Medicare claims files through the CMS Virtual Research Data Center, which enables hospitals to begin their analytics now, Fuller said.
But while some have started, TEAM's scope makes it challenging to evaluate potential impacts, an American Hospital Association spokesperson wrote in an email.
In particular, CMS’ decision to include markets with high numbers of safety-net hospitals and hospitals that have not previously participated in payment models makes the timeline a difficult to meet, particularly with many details left to iron out, the AHA spokesperson wrote.
America's Essential Hospitals Director of Policy Rob Nelb called on CMS to delay TEAM given its mandatory nature and the parlous state of safety-net hospital finances.
Clinical strategy
Once hospitals have enough data, they’ll need to come up with clinical and operational strategies for coordinating care and reducing readmissions.
One major piece is rethinking the financial incentives, Fuller said. “Readmission under a fee-for-service system is revenue, but readmission under a bundled payment reimbursement system is a financial loss,” he said.
Since TEAM focuses on readmissions within a 30-day window, hospitals will need to start building relationships with post-acute care providers to help ensure readmissions are reduced, Fuller said.
Over the next year, CMS will share additional resources on reconciliation, quality measurement and data collection, and will host webinars and office hours to support participants, the agency spokesperson wrote.
Care coordination
As part of their strategy to reduce readmissions, CMS gave hospitals permission to enter into gainsharing arrangements with providers that can help improve care continuity, but did not require it.
Before hospitals can start doing so, the agency will need to provide additional information on what is acceptable, Fuller said.
The most notable unresolved issue is the lack of fraud and abuse waivers, the AHA spokesperson wrote. The CMS Center for Medicare and Medicaid Innovation is permitted to disregard certain fraud and abuse laws when testing payment and service delivery models. If CMS were to waive these rules, it would come through a future rulemaking, the agency wrote in the hospital payment regulation.
Without those waivers, hospitals have no real ability to make sure collaborating providers are helping achieve the TEAM's goals, the AHA spokesperson wrote.
“Fraud and abuse waivers are consistent with [the Health and Human Services Department's] efforts to broaden the use of value-based payment models and essential to enable hospitals to form financial arrangements with other providers collaborating in the model,” the AHA spokesperson wrote.
Discharge planning
Hospitals will need to strengthen their post-acute care networks so they can be sure patients are receiving continuous care, but workforce shortages and backlogs for post-acute care could complicate that, Fuller said.
TEAM could worsen the bottleneck, which would undermine the agency’s aim to reduce care fragmentation, Fuller said. It could also create relationships between post-acute care providers and hospitals in which beds are left open for patients being treated under TEAM — a scenario that might worsen care delays for other patients.
“When you've got financial risk, reimbursement, attached to a patient, there is some degree of prioritization that has to take hold,” Fuller said.
Mark Miller, executive vice president of healthcare at Arnold Ventures, said bundled payment models produce mixed results when CMS looks to mitigate fragmented care.
Conceptually, TEAM moves Medicare toward holistic care and, at a minimum, bundled payments may lay the groundwork for future participation in accountable care arrangements, Miller said.
But alternative approaches such participation in accountable care organizations might do more to move the needle on quality than bundled payments. Likewise, although the mandatory nature of the TEAM is positive, Miller said a more comprehensive approach might be more meaningful.
“Do you want to do this service-by-service, episode-by-episode?” Miller said. “If it's hard to get transformation — and it is — and you're asking providers to make significant changes and there's a limited amount of bandwidth, I'd go for the whole patient, versus the service-by-service approach.”
