The Uncertain Fate of Bundled Payment Models

With the departure of former Health and Social Services Secretary Tom Price from the agency, many may be wondering what this means for the future of grouped payment models Mandatory, Price being a virulent critic of these models. With the finalization of the CMS rule repealing the Episode Payment Models (EPM) and Cardiac Rehabilitation (CR) incentive payment model, as well as making the Joint Full Replacement Model (CJR) voluntary in the half of its geographical area, this issue is more urgent. Although Price is gone, industry sources believe that mandatory packages will not be pursued soon.

Effects up to now

The CJR model was launched in 2016 in 67 mandatory geographic areas with the goal of improving the quality and increasing the effectiveness of hip and knee replacements, interventions the most common of Medicare. With more than 400,000 hip and knee replacements in 2014, costing taxpayers over $ 7 billion for the hospitalization of these patients, these services were targeted for change.

After the first year of the program, initial results show that about 47% of the 799 participants in the RCJ realized cost savings totaling more than $ 37.5 million in reimbursements, including the number of participants. Hospital for Special Surgery New York. $ 1.3 million in reconciliation for its 850 surgical procedures. The remaining facilities, even if they do not generate savings, will not have to reimburse the CMS during this first year of performance.

To be eligible for a reconciliation payment, hospitals must obtain a rating of acceptable quality, good or excellent. For these rankings, 201 of the 328 hospitals receiving reconciliation payments scored well, 150 were excellent and 31 were acceptable.

The paths to success

Due to the disparity in nationally available resources, many health care groups oppose these groups being mandatory, but their implementation may have great benefits for a hospital.

The answer to the proposed rule brought some interesting ideas. The American Society of Anesthesiologists submitted comments stating that it appreciated that the CJR model was voluntary in many areas, but that CMS wanted to better understand the contributions of specialists on patient care. Alternatively, comments of the National Coalition on Health Care requested that the number of mandatory geographical areas participating in the RCJ be no longer reduced and asked to allow voluntary participation in the program. national scale. Comments from the American Hospital Association (AHA) supported the voluntary participation of rural and low volume hospitals, but felt that the low volume threshold was too low. AHA has also requested a waiver system for hospitals facing public health emergencies and public disasters. An expansion of voluntary participation can benefit organizations that have been ahead of the curve. CMS is going ahead with a derogation proposal for difficulties, but it does not agree with the other comments.

Baptist Health System in San Antonio began testing pooled payments in 2008, eight years prior to the implementation of its mandatory experience, and saw its average cost for uncomplicated joint replacements decrease from $ 26,785 to $ 21,208. between July 2008 and June 2015. Academy recently spoke with representatives of of Transformant Health Solutions who worked with OrthoCarolina, a private practice group not subject to the RGC rule, to create total bundles hip and knee replacement in 2012. This organization% reduction in cost per patient according to the insurer, reduction of 0.9 day of the length of stay and patient satisfaction of 98%.

While the EPM and CR models will face an untimely end and the CJR will be reduced, organizations can still leverage the meeting of hospitals and physician groups to find future innovations and HBI can help identify lucrative solutions.

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