CMS Bundled Payments Move Forward

Officials at the Centers for Medicare and Medicaid Services in August released a request for applications (RFA) inviting physicians, hospitals, and other health care providers to participate in the Bundled Payments for Care Improvement initiative. The program, which was mandated under the Affordable Care Act, offers options for bundling payments for a hospital stay, for post-discharge services, or for both the hospital stay and the post-discharge care.

Instead of paying hospitals, physicians, and other providers separately, this initiative would combine the payment over an episode of care for a specific condition. The aim of the program is to encourage clinicians to work together and provide better continuity of care, resulting in better quality and lower costs.

"Today, Medicare pays for care the wrong way," Health and Human Services Secretary Kathleen Sebelius said during a teleconference to announce the bundling program. "Payments are based on the quantity of care, the amount of services delivered, not the quality of that care. And that leaves us too often with a system that actually can punish the providers that are most successful at getting and keeping their patients healthy."

The new bundling program offers three ways for health care providers to receive payment retrospectively, and one way to receive a prospective payment. Under some of the retrospective payment models, CMS and the providers would agree on a target payment amount for the episode of care and providers would be paid under the original Medicare fee-for-service system, but at a negotiated discount of 2% to 3% or greater. At the end of the care episode, the total payment would be compared with the target price and providers would be able to share in the savings, according to CMS.

Under prospective payment model, CMS would make a single bundled payment to the hospital to cover all services provided during the inpatient stay by the hospital, physicians, and other providers. That payment would offer at least a 3% discount to Medicare. Under this option, physicians and other providers would submit "no pay" claims to Medicare and the hospital would pay them out of the single bundled payment.

In addition to the options of prospective or retrospective payment, providers could choose how long the episode of care will be and what conditions they want to bundle payment for, and what services would be included in the payment. CMS officials said they wanted to make the program flexible so that a range of hospitals, physicians, and other providers could participate.

The American College of Surgeons General Surgery Coding and Reimbursement Committee (GSCRC) has been actively studying how bundled payments could be applied in surgery. The ACS believes that critical to the success of any bundling initiative is ensuring that the bundle is clinically coherent. The ACS GSCRC will continue this work and their discussions with the administration, CMS, and other stakeholders to ensure that any possible bundled payments in surgery will improve patient care.

Organizations interested in applying must submit a letter of intent by Sept. 22 for Model 1 and by Nov. 4 for Models 2, 3, and 4. More information on the program and how to apply is available at www.innovations.cms.gov/areas-of-focus/patient-care-models/bundled-payments-for-care-improvement.html.

Dr. Richard Gilfillan, the acting director of the CMS Innovation Center, which is overseeing the bundling initiative, said he expects that hundreds of organizations will apply. The program is a unique opportunity for hospitals to redesign their systems to promote better care coordination, Dr. Gilfillan said, and have that effort supported through Medicare payments.

The idea is to eliminate the traditional barriers between physicians and other providers – both inpatient and outpatient – all of whom may be involved in the care of a single condition, said Dr. Nancy Nielson, senior advisor to the CMS Innovation Center and past president of the American Medical Association.

The AMA was still reviewing the bundled payment details at press time, but Dr. Cecil B. Wilson, AMA immediate past president, said the organization will urge federal officials to encourage applications for physician-led bundling projects. "For this to be successful, and for physicians to participate actively, then they need to be a part of that process rather than just some larger corporation or larger hospital system or health plan that’s organizing these," he said. "We think those are important as well, but we also think it’s important that physicians be a part of that leadership."

Health care consultant Robert Minkin urged physicians to seriously consider applying for the bundling program. The program is a sentinel event in the move from fee for service to more centralized, coordinated care model, he said.