10 Mar Bundled Payments in a Time of Uncertainty
AMI, CABG, and SHFFT EPMs and Commercial Bundles
Rocky Edmondson, RN, BSN, MBA, CCRN, Senior Director, Bundled Payments, Care Redesign & Management Advisors, xG Health Solutions, March 10, 2017
Each day when we turn on the news we are confronted with the terms “repeal and replace”, referencing the Affordable Care Act (ACA) and a direct implication for those utilizing the insurance exchange. As recent as Monday (3/6) the Republican controlled House of Representatives, led by Paul Ryan, introduced the American Healthcare Act, with the intent to repeal and replace the ACA. However, it would appear that the bill in its current form faces significant headwinds, which could delay or prevent it from becoming law. And while the ACA has been the catalyst for the movement in care delivery models from fee-for-service to value-based care, of which bundled payments are a key element, uncertainty still persists. So what does this mean for bundled payments going forward?
We recently had the opportunity to present and interact at several meetings and conferences, which had some of the brightest healthcare minds in attendance. Here is what we observed:
Improving care and reducing cost. Once you cut through the noise surrounding the “repeal and replacement” of the ACA, the fact remains that bundled payments have proven to improve quality and reduce cost. Additionally, bundled payments have enjoyed wide bipartisan support. However, with the confirmation of Dr. Tom Price to head the Centers for Medicare and Medicaid Services (CMS), the future of mandatory bundled payment programs remains in flux, especially the AMI/CABG and SHFFT episode payment models (EPMs). Many healthcare organizations I spoke with are moving forward with evaluating their current care in these areas utilizing data analytics, and establishing a plan to succeed under these EPMs. They are moving forward with the assumption that these EPMs will be implemented at some point, and if not, they will at least be well on their way to improving care and reducing costs for this population of patients.
Commercial bundles – Improving revenues and maintaining market share. As noted in previous blogs, many private payers are turning to bundled payments as a means to improve quality and outcomes, while reducing costs. As a result, healthcare organizations are starting to see the potential of commercial bundles in improving revenues, and maintaining market share, while displaying improved quality and outcomes within their organizations. These providers are eager to be the first to market with a commercial bundled payment product, therefore generating interest from payers and employers. The idea is that by providing bundled payment programs to payers and employers, the organization will become the preferred treatment site for the patients represented by employers and payers.
Whether it be episode payment models from CMS or commercial bundles, these are complex undertakings for most healthcare organizations. It’s important to note that the final EPM rules from CMS were 1,759 pages and covered many topics. The ability to succeed in commercial bundles, or the new EPMs from CMS, is dependent on proper preparation and the understanding of the nuances of these programs, including: data analytics, program development, implementation, and risk management.
Are you prepared to succeed in these and other value-based programs? Are you interested in learning how to be successful in bundled payments? If so, please feel free to contact Rocky Edmondson at email@example.com or Andrew Blackmon at firstname.lastname@example.org.