Provider Organizations Express Concerns With Bundled Payments Program

Not allowing post-acute care (PAC) providers to take the lead in the Bundled Payments for Care Improvement Advanced (BPCI Advanced) program will hamstring the government’s ability to improve savings and care, several associations argued in a letter to the Center for Medicare and Medicaid Innovation (CMMI).

LeadingAge and other prominent long-term care associations raised concerns about BPCI Advanced in the March 1 letter.

“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,” the associations and Dr. Terrence O’Malley, a teaching geriatrics fellow with Partners Healthcare, said in the letter.


BPCI Advanced, which was introduced on Jan. 9 by the Centers for Medicare & Medicaid Services, prevents PAC providers from being episode initiators, though they can work with such participants in the model. The application deadline was Monday, however, which the letter argued did not allow enough time for PACs to get a foot in the door with so-called “upstream” providers.

The signers of the letter included LeadingAge, which represents more than 6,000 not-for-profit senior care providers; AMDA – The Society for Post-Acute and Long-Term Care Medicine; ElevatingHOME; the National Association for the Support of Long Term Care; the National Association of Home Care & Hospice; and O’Malley.

The letter, which was addressed to Amy Bassano, the acting deputy administrator for CMMI, outlined several concerns with BPCI Advanced, such as the exclusion of PAC providers from episode initiator status and insufficient time to complete the tasks needed for the BPCI Advanced application, among others.


Permitting only bundles led by hospitals and physician group practices (PGPs) does not do much to drive changes in care costs at hospitals, which the letter said are the highest-cost care setting.

“Offering the option for PAC providers to continue to participate but only as conveners of ‘upstream’ providers fails to recognize the practical reality in the marketplace,” the letter argued. “For several reasons this is an impractical role for PAC providers. As a Convener Participant, a PAC provider would bear financial risk for the Episode Initiator…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 letter called upon CMMI to commit to amending the model to allow PAC providers to be episode initiators and to changing some program requirements that could pose barriers to entry. It also asked CMMI to convene a group of PAC and long-term service and support (LTSS) providers to develop and test alternative payment models that them take the lead.

The American Health Care Association (AHCA) also expressed worries about the BPCI Advanced model, though it was more measured in a statement provided to Skilled Nursing News.

“AHCA was disappointed in the absence of a clear role for PAC providers in BPCI-Advanced,” Mike Cheek, senior vice president of reimbursement policy at AHCA, said in the statement. “However, we look forward to a dialogue with CMMI on strategies to engage PAC providers in future strategies.”

Written by Maggie Flynn

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