This week the Centers for Medicare & Medicaid Services (CMS) announced a new mandatory bundled payment program for cardiac care. The proposed 5-year demonstration would go into effect on July 1, 2017, in 98 to-be-identified markets. The model would make hospitals financially accountable for the cost and quality of care for acute myocardial infarction (AMI) and coronary artery bypass graft (CABG) during inpatient stays and for 90 days following discharge. Continue reading
CMS’s new proposed rules related to the Bipartisan Budget Act of 2015 would severely inhibit hospitals’ ability to expand and modify outpatient service offerings around the country. Issued on July 6, the regulations have yet to be finalized and comments are being requested; however, hospital planning executives are understandably fuming about the restrictive and complicated rules, which would compromise their ability to conduct provider-based billing at outpatient sites located more than 250 yards beyond the hospital walls. Of particular interest is the direct comment by CMS that Section 603 was designed to curb hospital acquisition of physician practices and the current practice of providing the same services under a higher-cost model of OPPS. Continue reading
This post was written by Jessica Turgon, Principal, Matt Sturm, Senior Manager, and Meagan O’Neill, Senior Consultant.
Earlier this week the Centers for Medicare & Medicaid Services (CMS) announced the nearly 200 organizations that have been selected for participation in the Oncology Care Model (OCM), one of the new payment and care delivery initiatives introduced by the Center for Medicare & Medicaid Innovation (CMMI) in 2015. The 5-year pilot is slated to begin July 1, and according to CMS, the number of participants is twice the size as initially anticipated – it will include approximately 3,200 oncologists and provide coverage for 155,000 Medicare beneficiaries. Continue reading
An atmosphere of urgency permeated the National Bundled Payment Summit in Washington, D.C., earlier this month. That shouldn’t be surprising, given the number of major announcements in the first half of 2016 related to bundled payments. Between rolling out two new programs and extending the Bundled Payments for Care Improvement (BPCI) initiative, CMS has signaled its ongoing commitment to bundled payments.
With the unprecedented growth of these initiatives over the past 5 years – including the CMS-mandated Comprehensive Care for Joint Replacement (CJR) program – there are more questions about bundles than answers. But as this year’s Summit demonstrated, that sense of uncertainty is at least matched, if not exceeded, by a growing resolve to thrive under episode-based reimbursement.
Bundles Take Flight
Sponsored in part by ECG Management Consultants, this 3-day event brought together providers, physicians, policymakers, payors, patients, and healthcare executives – a clear sign that the growth of bundles affects a wide range of industry stakeholders.
The Summit’s breadth and diversity of participants also served to underscore a fundamental truth: bundled payments are here to stay, but at the same time, they’re still evolving. No entity or organization has fully mastered this concept, but many are building on their BPCI experience to expand their bundle initiatives. One attendee likened it to “still building an airplane while we’re flying it.”
Remarks like that don’t exactly inspire confidence. But if you are in position of building an airplane while it’s in flight, you’ll want to have the best engineers on board with you. Fortunately, the Summit gathered some of the top leaders and thinkers within bundled payments.
Co-chairing the Summit were Deirdre Baggot, leader of ECG’s Bundled Payments Practice, former Expert Reviewer of the BPCI initiative, and former Lead for the Acute Care Episode (ACE) demonstration; and Erin Smith, Vice President and Executive Director of the Post-Acute Care Center for Research and former Director, Division of Technical Model Support, and Lead, for BPCI.
Baggot and other members of ECG’s Bundled Payments practice led a pre-conference session called “The CJR Playbook: Real-Life Best Practice in Smart Implementation.” It was an interactive session that presented a strategic roadmap for CJR implementation and offered proven best practices and recommendations from successful programs across the country. Baggot emphasized several key themes, most notably the need for bundled payment programs to be scalable and economically feasible.
And while Baggot and her team brought data and case studies to support the benefits of bundled payment initiatives, they were candid about the challenges. Baggot cited the need for “failure tolerance” and urged attendees to view failure as nothing more than a data point. ECG Senior Manager Kimberly Hartsfield summed up the challenges succinctly: “This is innovation. This work is hard. If it was easy, you wouldn’t be sitting here today.”
The first full day of the Summit began with a keynote address from Amy Bassano, Deputy Director, Center for Medicare and Medicaid Innovation (CMMI). Bassano gave what you might call a “state of bundled payments” address, focusing on the parameters and rationale of the three Medicare Models – BPCI, CJR, the Oncology Care Model (OCM) – while promising that CMS would be testing new models and expanding existing ones.
Attendees seemed to appreciate the opportunity to hear directly from CMMI, but a presentation from Mount Sinai Health Partners’ Lindsay Jubelt, M.D., Medical Director, and Alexis Kowalski, Senior Director, offered an on-the-ground perspective of implementing bundled payment initiatives. At the heart of their presentation was the importance of ensuring that physicians are invested in the bundled payment concept. “If we’re going to transform healthcare, we need physicians to lead it,” Jubelt said. “We need to turn physicians into partners – engage them in the care transformation process.”
The Summit’s focus on Medicare bundles made a presentation by a commercial payor all the more intriguing. Representing Horizon Blue Cross Blue Shield of New Jersey, Lili Brillstein, Director of Episodes of Care, and Joseph O’Hara, Director of Market Innovation, discussed the challenges of paying for care in New Jersey. Horizon experimented with episode-based care as a means to address costs, and since 2011, they’ve seen improvements in the form of higher quality, lower costs, and greater consumer satisfaction.
CMS was on hand to close out the conference. Patrick Conway, M.D., is Deputy Administrator for Innovation and Quality, Chief Medical Officer, and Director of CMMI, as well as the Director, Office of Clinical Standards and Quality, at CMS. Sharing early results of the shift toward value-based payments, Conway claimed that Medicare spent $473.1 billion less on personal healthcare expenditures between 2009 and 2014 than it would have spent if the 2000–2008 average growth rate had continued through 2014. That amount could grow to $648.6 billion if trends continue through 2015.1
Encouraging as those figures may be, the conference ended not on a note of triumph, but on one of determination. A recurring theme among speakers and attendees was that this journey toward value had only just begun, and the road will not be easy.
Still, a sense of optimism prevailed. “Organizations were hopeful that a next-generation BPCI would be introduced by CMS, and leaders were excited for the chance to participate in a bundled program if they weren’t in one yet,” noted ECG Senior Manager Tori Manis, who led several panel discussions.
The Summit was also notable for its engagement following presentations and panels, with healthcare executives and CMS representatives willing to respond to tough questions from stakeholders from across the continuum. Many inquired as to what would be the next area of focus for mandatory bundles; speculation centered on cardiac surgery. Another common question concerned how behavioral health could be integrated in a bundle. Conway himself called behavioral health “a huge opportunity for improvement.”
It wasn’t long ago that a pair of senators in Congress attempted to slow the growth of bundled payments initiatives, and there’s no doubt that change will continue to be gradual. But the overwhelming attitude at the summit was that it’s time to figure this out.
In the recent proposed rules for MACRA, CMS offered some clarity for providers who are trying to decide whether to participate under the Merit-Based Incentive Payment System (MIPS) or the Alternative Payment Model (APM) track. In short, it really is not a decision that the provider makes, but rather a determination made by CMS based on the provider’s level of participation – if any – in qualifying APMs (also known as advanced APMs). Continue reading