Bundled Payments: Looking Back, Looking Ahead

The year 2019 was a fascinating one in value-based policy around bundled payments. The original Bundled Payment for Care Initiative (BPCI) wound down even CMS teased several new value-based payment initiatives. Meanwhile, the continuing maturation of other bundled programs shed some light on what we might be able to expect from the future.

Here are our top takeaways from 2019 and expectations for 2020.

The Sunsetting of BPCI Classic

The DataGen team has been watching the final run out of the original BPCI program. The last set of reconciliation reports was delivered in December, officially closing out the CMS Innovation Center’s first experiment in designing bundled payments. While this program wasn’t perfect, it served as a testing ground for a number of new ideas—ideas that have been refined and included in a number of other bundled payment programs.

When the program started, CMS was still working to find the right definition of how long an episode should be, how much risk is too much risk for providers, and what type of providers should be participating. In retrospect, one of the program greatest impacts was showing providers that they could become more actively engaged in care coordination beyond the initial hospitalization—and to look at utilization in a productive way, to reduce expenditures and improve quality. It showed that the move towards a value-based model is something that can actually be done.

The Maturation of BPCI Advanced

BPCIA progressed through its second model year and opened enrollment for a second cohort of participants to enter in model year 3. Participation decisions for 2020 were only recently made, so we’re still waiting to see how enrollment changed from the first cohort.

BPCIA participants also went through the initial reconciliation of the first performance period mid-November. Many episode initiators were pleasantly surprised to see positive financial results, something that’s given many stakeholders a positive outlook on the program going into the next year.

One of the overarching hopes of BPCIA is that it will help participants achieve value-based practice transformation. But, as with any new program, no matter how closely participants follow the methodology and study how the target prices will work, it’s difficult to know what impact has been made prior to the release of reconciliation results. Now, practices are evaluating if they’ve achieved success, whether it be in terms of reducing expenditures or improving quality.

A Potential Extension for CJR?

The Comprehensive Care for Joint Replacement (CJR) program is completing its fourth year and is about to enter its final year. Rumor has it that a proposed 3-year extension to the program is being reviewed at the Office of Management and Budget. We will be anxiously waiting to learn more about the future of CJR in the year to come.

We certainly hope an extension happens. In many ways, lower extremity joint replacements bundles are the best place for organizations to begin learning about value-based payments, and why bundles can be so beneficial. The program has generated a lot of success over the past 4 years, so it would be a shame to see it end at this point.

Next steps for OCM

The Oncology Care Model (OCM) is also advancing into its final year of new episodes in 2020. While increasing numbers of participating practices have managed to reach their financial goals, those who haven’t received a performance based payment reached a critical crossroads this year. Practices had to decide if they would take on 2-sided risk or exit the program. Fortunately, we’ve seen a number of practices see value in their continued participation and a willingness to take on some risk in the coming year.

While OCM is a complex and difficult program, the fact that many participants have reached the confidence level necessary to take on 2-sided risk speaks volumes, and is a ringing endorsement for people seeing the real value in a value-based program.

New Programs on the Horizon

The programs that CMS has announced for 2020 appear to be targeted at getting more types of providers, such as radiation oncologists, ambulatory care providers, and primary care providers, involved in value-based models. Here’s a breakdown of some of the programs CMS has announced:

• Radiation Oncology: This program, which would be mandatory for parts of the country, only includes technical and professional radiation oncology services; it is not a total cost of care model. Look for a final rule to be published in early 2020.
• End-Stage Renal Disease (ESRD) Treatment Choices: This program also could be mandatory for parts of the country. Its goal is to promote home dialysis and increase transplant rates. Serving as a new example of a value-based specialty care model, this program includes payment adjustments to providers.
• Oncology Care First: When OCM ends, this is a proposed voluntary model that may into place next. Much like the evolution from BPCI to BPCIA, this will build on the lessons learned in the original OCM model.
• Primary Care First: This new voluntary model will be built around some elements of risk sharing. It will be open to practices providing advanced primary care services, and marks a concerted effort to strengthen the front line of care.
• Emergency Triage, Treat, and Transport: This will be a voluntary model focused on ambulance suppliers and providers for emergency health needs. It will give participating providers the ability to triage patients to an alternative care site (rather than just the ED) or to provide treatment in place in appropriate situations.

All in all, it’s a very interesting time for alternative payment models. We at DataGen are excited to see what the future holds. As CMS improves on past iterations of models, our hope is that the programs to come will demonstrate to a wider pool of providers the value and benefits they can achieve through value-based care. Reach out to us today to learn more.

About the Author

Alyssa Dahl is Director of Informatics at DataGen, a healthcare data analytics and policy firm.