Orgs Troubled by Post-Acute Care’s Role in New Bundled Payments
Industry groups voiced their discontent with the diminished role of post-acute care providers in the new Medicare bundled payments model, the BPCI Advanced.
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By - Long-term and post-acute care provider organizations recently voiced their concerns with the new Bundled Payments for Care Improvement (BPCI) Advanced model’s reduced role of post-acute care providers.
Eliminating the post-acute care-only bundles from the original BPCI initiatives and preventing post-acute care providers from serving as episode initiators could jeopardize the success of the new bundled payments model, explained LeadingAge, the Society for Post-Acute and Long-Term Care Medicine, National Association for the Support of Long-Term Care, and three other groups.
“For our members who currently participate, they sought continued opportunities to improve care for the older adults they serve,” the groups wrote to Amy Bassano, CMS Acting Deputy Administrator for Innovation. “Needless to say, we were surprised by the direction of and changes to the new model. Specifically, we are concerned that by minimizing the role of post-acute care (PAC) providers, CMS is missing an opportunity to improve overall care delivery and, potentially, realize efficiencies and cost savings.”
Post-acute care providers in the original BPCI initiative realized care efficiencies and cost-savings. The October 2017 evaluation report of the bundled payments model revealed that skilled nursing facilities in the post-acute care-only track reduced major lower joint replacement episodes by 7.1 percent, and home health agencies in the track reduced Medicare spending by 3.6 percent for congestive heart failure episodes.
With preliminary data showing success with the post-acute care bundled payments, the industry groups questioned why the BPCI Advanced did not include a similar pathway for post-acute care providers.
READ MORE: Understanding the Basics of Bundled Payments in Healthcare
Failing to include the post-acute care-only track in the BPCI Advanced also harms providers who were participating in the track under the original bundled payments model.
“This position, eliminating successful Model 3 participants, is a waste of resources — time, staff, expertise gained so far, etc. — that were dedicated to care redesign and improvement,” the groups stated. “Instead, CMS is outright abandoning these providers who will financially fail if they continue the care redesign practices they employed under BPCI, as they will lose fee-for-service per diem revenue from shorter lengths of stay and fewer PAC episodes without any reward for savings that will accrue to Medicare.”
Post-acute providers do have the opportunity to earn incentive payments under the BPCI Advanced model by acting as conveners, but not episode initiators. However, the industry groups did not view this as the appropriate role for post-acute care organizations.
As conveners, post-acute care organizations would assume the financial risk of all of the care episodes of the episode initiator, which is either an acute care hospital or physician group practice in the BPCI Advanced. This would include the episodes in which the initiator discharged patients to another post-acute care facility.
“This scenario would place extraordinary risk on the PAC provider with little say in the discharge location and consequently the services provided at those settings,” the groups said.
READ MORE: Key Strategies for Succeeding with Healthcare Bundled Payments
Hospitals and physician groups are also unlikely to allow post-acute care providers to control their bundled payments as conveners, preferring to take on the risk themselves in order to control the financial incentives.
But even in the situation where an episode initiator would allow a post-acute care provider to serve as a convener, there is not enough time to build the relationship necessary for bundled payment model success.
“[T]here is inadequate time for conversations between PAC provider conveners and ‘upstream’ providers to ensue and memoranda of understanding to be completed in advance of the application deadline,” the letter stated. “Therefore, one can assume that CMS really is only seeking limited participants in this new model and they should be ACHs [acute care hospitals] or PGPs [physician group practices] who already have established relationships. Innovation and partnerships take time to build.”
To rectify the shortcomings of the BPCI Advanced model, the industry groups suggested that the CMS Innovation Center issue guidance that will allow all current participants in the post-acute care-only track of the BPCI to extend their contracts for another three to five years or until a replacement program is developed.
In terms of the BPCI Advanced, the center should also amend the bundled payments model to include post-acute care providers as episode initiators and ensure the requirements, such as certified EHR use, do not create entry barriers.
Finally, the industry groups recommended that CMS gather post-acute care and long-term service and support providers to create and test alternative payment models that enable these provider types to lead innovative care models, assume financial risk, and share in the financial rewards.
