Reaction to the Centers for Medicare and Medicaid Services' new voluntary bundled payment models is in a word, positive.
There's something in the 29 inpatient and three outpatient clinical episodes for everyone, including physicians who were left out of the first bundled payments for care improvement initiative.
The new bundled payments for care improvement advanced is the first time BPCI qualifies as an advanced alternative payment model, and its 5 percent bonus, under MACRA.
This gives incentive for volunteers, including physicians, to sign up.
While hospitals have the analytic capabilities, being in the boardroom doesn't drive clinical drive change, said Christopher Stanley, MD, with Navigant.
Getting physicians onboard has long been the goal of any value-based initiative, whether it be bundles, shared savings, or accountable care organizations.
Hospital executives have told him that they thought they had good relationships with doctors before, but the level of engagement resulting from the new model has exponentially improved that relationship, said Stanley, a director for Navigant within value transformation in the healthcare practice.
"We can actually have doctors lead the initiative," Stanley said. "This is what we've been wanting to do this for years."
Stanley said he doesn't expect the floodgates to open in having physicians jump from MIPS to the advanced alternative payment model through BPCI Advanced. That may take two or three years because of the infrastructure needed.
But another reason to get excited is that bundles have shown they're doing their job by saving money and improving quality, according to those interviewed.
Navigant helped Baptist Health System in San Antonio achieve through BPCI 1.0, a 21 percent reduction in Medicare payments at a time when the nation saw increases of 5 percent. It saved $11 million-plus for the health system, split equally between acute and post-acute care, Navigant said.
Archway in Massachusetts, which works with about 100 providers nationwide, has reported cost savings of $2,000 to $4,000 per bundle, according to Keely Macmillan, general manager of BPCI Advanced.
NaviHealth works with about 50 hospitals across the country. Last year naviHealth helped them save $83 million through BPCI, according to CEO Clay Richards.
"All of our hospitals are saving money," Richards said. "On the post acute side we've seen double digit savings."
BPCI 2.0, released on Jan. 11, replaces the current BPCI 1.0, which ends on Sept. 30. BPCI Advanced starts on Oct. 1 and runs through Dec. 31, 2023. The application deadline is March 12.
Providers are still awaiting further details on the voluntary model, such as target pricing and benchmark methodology, which CMS should be releasing imminently, according to Macmillan.
Last year, CMS cancelled or scaled back on mandatory bundled models for joint replacement, hip fractures and cardiac care, but promised to release new voluntary models.
Some questioned whether the move by the new administration to cancel mandatory bundles also meant a scaling back of value-based care.
"The takeaway was whether the administration or healthcare in general would pull away from value-based programs," Stanley said.
Now, hospitals can move forward confident that value-based initiatives and investments will pay off, both financially and in quality of care.
"This does not take our foot off the gas from moving to value," Stanley said is the reaction. "Now BPCI advance is further evidence CMS is continuing down that road for value. I would anticipate more coming out of the provider and CMS world and we're certainly seeing interest as well in the commercial payer side. We've very bullish on doing more and more in value-based programs."
BPCI bundles that have shown great success include lower extremity joint replacement for hip and knees.
In the latest model, CMS dropped about 20 bundles that did not achieve good results, notably for chest pain and diabetes.
An outpatient knee bundle, which everyone expected would be included, is missing from the new model, Macmillan said.
Overall, she said, "I think the new outpatient bundles are really compelling. There's a tremendous opportunity to achieve efficiency. There's strong interest. Generally the market has matured and evolved. Many are more prepared to enter into a risk-based program."
The voluntary bundled model gives incentive payments if all expenditures for an episode of care are under a spending target that factors in quality.
Participants may receive payment for performance based on 32 different clinical episodes, including for the first time, three outpatient episodes.
The post-discharge time period has been set for 90 days in an episode, whereas previously some bundles had 30, 60, or 90 day timeframes.
An emergency room visit that triggers further treatment now becomes part of the bundle and is included in an episode of care.
Also, the new bundle model includes hospice care.
One of the challenges is the short timeframe for the October 1 start date of the program, for hospitals not already onboard with bundles.
Another is the challenge for providers in choosing the right bundles.
No one has the bandwidth to do all 32.
Making that decision requires data analytics and developing care pathways to engage all of physicians in a relative standardized process, Stanley said. This includes an electronic health record.
Care should be consistent and consistent pathways take time, he said.
CMS listened to feedback from providers that they wanted a target price set a year in advance instead of quarterly, Richards said.
The new model also takes into account regional factors, which providers said they wanted.