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Finding a Place for Bundled Payments in MACRA Implementation

A healthcare industry group has called on CMS to include bundled payment programs as APMs under MACRA’s Quality Payment Program.

By Jacqueline Belliveau

- As officials at the Centers for Medicare and Medicaid Services (CMS) sift through over 3,800 comments on the proposed rule for MACRA implementation, the Healthcare Incentives Improvement Institute (HCI3) has released its comment letter to CMS suggesting that bundled payments should qualify as alternative payment models (APMs).

Healthcare group urges CMS to include bundled payment programs as APMs under MACRA

“We are concerned that without important revisions the rule may slow progress in the current movement to broadly adopt alternative payment models,” said François de Brantes, HCI3’s Executive Director in an accompanying press release.

“CMS's proposal to ignore bundled payment models as advanced APMs, despite their broad appeal and substantial evidence of effectiveness, will cause significant harm to widespread adoption of APMs if it stands as written.”

The group explained that public and private payers are increasingly adopting bundled payment arrangements for various episodes of care. With employers, state Medicaid programs, CMS, and more using the model, HCI3 has expressed concerns that excluding the widely used reimbursement structure could slow down the healthcare industry’s move to value-based care.

Specifically, HCI3 stated that CMS bundled payment initiatives, such as the Comprehensive Joint Replacement (CJR) model and the Bundled Payments for Care Improvement (BPCI) program, should qualify as Advanced APMs under MACRA.

READ MORE: CMS May Cancel Upcoming Cardiac, Ortho Bundled Payment Models

“Rejecting these models as Advanced APMs would not only miss an opportunity to promote further adoption of promising payment approaches, but may also disrupt the focus of current participants in BPCI and CJR,” the letter explained. “Instead, bundled payments deserve CMS’s robust support.”

HCI3 added that the accountable care organizations (ACO) currently considered Advanced APMs do not reduce healthcare costs and improve care quality as much as bundled payments. Medicare ACOs and the Comprehensive Primary Care program, which have been identified as being advanced APMs, have not significantly improved affordability and quality of healthcare, according to research published in the New England Journal of Medicine.

However, CMS developed the CJR program due to its early success with the BPCI initiative, which demonstrated substantial healthcare savings. Yet, the models are not included as APMs under MACRA, explained HCI3.

Despite their ability to further value-based care, CMS has not included bundled payments as an Advanced APM because the models do not meet certified EHR use and quality measures requirements under MACRA.

“We propose that additional reporting requirements be added to the CJR and BPCI programs that will satisfy the certified EHR criterion, and that steps be taken to enable BPCI entities to include quality measures that will satisfy the quality criterion,” stated the letter.

READ MORE: PTAC Recommends 2 APMs for Potential MACRA Implementation

The industry group advised CMS to develop a set of evidence-based quality measures for clinicians who participate in the programs. CMS should consider measures that have already been established by the American Academy of Orthopedic Surgeons and certain state Medicaid programs that have tied quality measures to episodes of care.

CMS should also ask for participating clinicians to demonstrate certified EHR use to qualify bundled payments as Advanced APMs, HCI3 recommended. However, HCI3 advised CMS to require a lower reporting burden than the MIPS model. Additionally, the industry group found that bundled payment models are not appropriately valued in MIPS.

Under MIPS, eligible clinicians can earn credit in the Clinical Practice Improvement scoring category for participating in APMS. Yet, the CJR and BPCI programs are also not considered APMs in this reimbursement track and do not generate any credit through the MIPS scoring methodology.

HCI3 recommended that eligible clinicians in these bundled payment programs earn the same amount of credit as qualifying ACO participation as long as the programs are modified to satisfy the Advanced APM criteria.

Through the letter, HCI3 discussed how bundled payment programs are effective tools for promoting value-based care, which should be acknowledged in MACRA.

READ MORE: Oncologists Need Data Reporting, Time for MACRA Implementation

“In general, the bundled payment framework is the kind of model that can help CMS, and the healthcare industry at large, achieve the goal of better and more affordable care,” the letter concluded. “For these alternatives to achieve widespread adoption, however, it is essential that they can qualify under the MACRA’s Quality Payment Program.”

Another industry group published a letter last week voicing its support for bundled payment models. The Center for American Progress, along with other healthcare stakeholders, called on the Department of Health and Human Services (HHS) to develop and expand bundled payment programs.

By adding more national bundle payment demonstrations, HHS would be sending a message to the industry that Medicare plans to expand this model alongside other payment reforms, stated the Center for American Progress.

While some groups have urged the federal government to consider more bundled payment programs, others, like HCI3, are concerned that exclusion from MACRA could slow down the growth of these models. As the final rule on MACRA implementation draws closer, healthcare stakeholders may have to wait and see how bundled payment programs are going to factor into the new payment systems.

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