As the Center for Medicare and Medicaid Services (CMS) seeks to increase the cost effectiveness of healthcare, they have pushed for a switch from fee-for-service payment models to more value-based ones. One of the tools they have introduced is Bundled Payments for Care Improvement (BPCI). Like many of their other programs, they have a variety of voluntary (BPCI) and mandatory (CJR) options. As these programs have become more available, a debate has developed between healthcare executives about their value and efficiency. While the goals behind these programs are generally acknowledged, how they can best achieve them is still being improved.
The driving force behind bundled payments is the promotion of high-quality care by encouraging providers, through various rewards, to provide patient care during the entire care event at a predetermined cost. If the provider exceeds the predetermined target price, they are required to pay the difference back to CMS. In order for these programs to work at peak efficiency, greater coordination is required between different providers as well as the patient. As bundled payments require more customization, and in turn more coordination, providers are increasingly looking to technological advances to help facilitate this process as software and other technology facilitate quicker and more accurate data sharing.
Through incorporating technology in the patient engagement processes, providers are also engendering greater trust in their patients and empowering them to feel more in control of their healthcare decisions. In order to achieve these benefits, the right technology must be used. Hospitals that already have this technology in place have seen positive results. Several are successfully achieving the Key Performance Indicators (KPIs) put in place as part of the bundled programs they are participating in. KPIs that have yielded positive results include reduced readmissions and scalable patient engagement processes.
Hospitals have also used technology in leveraging patient information through automated calls and text messages, cross-continuum care coordination, and point-of-care data collection. One of the greatest areas of success has been for orthopedic care, such as knee and hip replacements, where savings have reached 5% of total costs, in addition to increased satisfaction amongst patients.
Accountable Care Organizations (ACOs) are also models that can benefit from bundled payments, as they often focus on specific populations of patients, such as chronic disease patients. By offering more incentives around quality, CMS is hoping to make participation in BPCI’s more attractive and beneficial. They are hoping that more coordinated care will better target specific communities and populations.
While most bundled payments are organized by procedure (such as orthopedic care), some are advocating for bundling by condition to broaden the scope of BPCIs and make them more effective. Some patients, who experienced by-the-book procedures and were deemed perfect according to the outlined conditions, needed additional healthcare to treat anxiety and depression due to those procedures. As it currently stands in some implementations, those conditions are not part of the specific orthopedic procedure and would not be included.
One hospital where they have incorporated this perspective is Dell Medical School at the University of Texas. Here, many providers use bundled payment models with care teams that include behavioral health specialists, nutritionists, physical therapists, chiropractors, acupuncturists, advanced practice nurses, and surgeons. Just as the procedural level bundles encourage better care coordination among acute and post-acute providers, bundling at the condition level promotes better care coordination across an array of providers who manage various conditions.
By incorporating nutritional and behavioral health-related services, patients overall health can be addressed and treated. Dr. Kevin Bozic of the Dell Medical School in Texas emphasized that “bundling at the procedure level limits value creation by ignoring the concept of appropriateness.” Bundling by condition improves care coordination, helps remove the incentive for more procedures, and measures what matters most to patients — pain, quality of life, functional status, and overall mental health.
Due to the variety of ways to incorporate bundled payments, Premier Inc., a leading healthcare company, issued a best practice guide for their participating providers outlining how best to reap the benefits of this program. Published in April 2018, they said declared that bundled payments “can be a vital strategic tool for health systems.” They continued, “while accountable care organizations (ACOs) require an organization-wide mobilization and assumption of risk that many find daunting, bundled payments can be tested within a few services lines, and expanded gradually if successful. Bundled payments also can create incentives to bring in providers that are traditionally left out of ACO or primary-care based models, including specialists and post-acute care providers that have a major impact on both costs and quality.”
Regarding the impact of technology on bundled payments, they stated that to be successful requires very specific technical capabilities across participating providers. Success, they believe, starts with data analytics to choose the best episodes with the greatest savings opportunities. Premier Inc.’s efforts to successfully implement bundled payments is one to keep your eyes on as they measure and report their success, as their 120 healthcare facilities comprise one of the largest collaborations of healthcare provider systems that focus on episode-based care.
While knowing how to put all the pieces together to achieve the most efficient bundled payment program can be daunting, looking at the success of others and learning from the lessons they share can boost your confidence as you start to craft your own program. As technological advances increase the speed and accuracy of vital information required to facilitate care coordination, we hope to see a corresponding increase in the quality and efficiency of care we can offer to those in need.