How to Navigate the Bundled Payments Roadmap

It seems like every few months, another “innovative” model of care is being announced, tested or touted as the ‘newest way to help save Medicare dollars’. The common thread between all of these models is to ensure that patients, especially the chronically ill, get the right care at the right time while avoiding unnecessary costs, medical errors and duplication of services.

Practices are reporting fewer patients in the traditional fee-for-service model, and instead, are trying to understand the nuances of providing care in these new value-based, bundled payments models. If you find yourself getting confused about how they are defined or how they differ from each other, you are not alone!

Let’s take a look at what we know now and what the future holds for rehabilitation specialists in the transition to value-based care.

The Road We’ve Travelled – The CJR Bundle

Last April, more than 750 hospitals began participating in the Comprehensive Joint Replacement (CJR) bundle. These bundles include episodes of care triggered by a hospitalization for a total knee or total hip replacement with/without complications or comorbidities as well as all the Part A and Part B services (with a few exceptions) associated with the care for 90 days post-hospitalization. Participating in a bundled model was both scary and overwhelming to many hospital and post-acute care providers. Since most of these settings never needed to think about the care provided outside of their walls, the new model means increased focus on a patient’s entire care continuum.

Episode payment models (EPMs) are not going away. Even with the new administration in place, it is highly likely providers will continue to see more chronic and/or costly conditions moved into EPMs. The primary drivers being cost and efficiency.

Case Study in CJR – Decreased Costs & Increased Efficiency

To understand the initial impact of EPMs, one needs to look at performance data that CMS provided to participating hospitals. The data tells each setting how well they performed compared to their “target” for the 90-day period. A recently published study in JAMA Internal Medicine reported one hospital system’s experience in two voluntary bundling programs over a seven-year period (2008 to 2015).1 The system’s 5-hospital network in San Antonio, Texas participated in both the Acute Care Episode (ACE) demonstration and the Bundled Payment for Care Improvement (BPCI) program for joint replacements. A total of 3,942 patients with an average age of 72.4 years participated in these programs. Over seven years, the hospital network saw the following results:

  • The average Medicare episode payment for joint replacements without complications decreased by 20.8% ($5,577).
  • The average for joint replacements with complications decreased by 13.8% ($5,321).

While the patient demographics did not change over this period, the number of replacements rose steadily. What accounted for the decrease in cost? This hospital system attributes it to two primary factors:

  1. Cost of the actual implant they used
  2. Decreased use of inpatient rehabilitation facilities (IRFs) and skilled nursing facilities (SNFs)

The Road Ahead – New Bundles & New Opportunity

More EPMs are scheduled to be initiated this October.

  1. Cardiac care bundles for acute myocardial infarctions and coronary artery bypass graft surgeries will start in 98 metropolitan areas and will be structured similar to CJR.
  2. Hospitals currently participating in the CJR bundle will add a new condition: Surgical Hip and Femur Fracture Treatments (SHFFT).
  3. Hospitals in 90 metropolitan areas will also be awarded incentive payments for providing cardiac rehabilitation.

Rehabilitation Services’ Role

Despite the natural apprehension that occurs with new payment and care models, rehab therapists are encouraged to learn more about the new models. The experience of one hospital system cannot be seen as the recipe for success in all communities. Thus, a thorough grasp of the new model is the best method for achieving lowered costs, increased efficiency, and optimized care.

While it is too early to fully understand the clinical care outcomes for patients in these models, rehabilitation therapists have an opportunity to champion the collection of this very important data point. Rehabilitation services are integral to the success of these models as well as improving the health of communities.

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  1. Navathe AS, et al. JAMA Intern Med. 2017;doi:10.1001/jamainternmed.2016.8263.