CMMI Could Put Post-Acute Providers Back in Control of Bundled Payments

The leader of the federal government’s center for reimbursement innovation said he is considering bundled payment models where post-acute care providers could take the lead on care — but right now it’s only at the consideration stage.

Adam Boehler, who leads the Center for Medicare and Medicaid Innovation (CMMI), said that there has been significant interest from the industry in post-acute care bundles in a speech at the annual meeting of the American Hospital Association earlier this week.

“Now is the time to raise ideas there,” he said at the gathering on Monday.


Modern Healthcare first reported Boehler’s remarks.

Given the early stages of the proposal and the concept, it’s hard to zero in on specifics of the post-acute bundled payment that CMMI is considering, Nisha Hammel, senior director of population health management at the American Health Care Association (AHCA) said in a statement provided to Skilled Nursing News. But future programs are going to reflect the move by the Centers for Medicare & Medicaid Services (CMS) from volume to value.

“Ideally, any future bundle would position post-acute providers to initiate the episode and hold and manage the bundle, leveraging their strengths to deliver quality care to patients with complex, on-going care needs,” Hammel said.


AHCA represents for-profit and nonprofit nursing home providers.

Bundled payments have caused some notable headaches for skilled nursing providers, as well as for the federal government: Multiple studies have found that bundled payments reduce spending by cutting post-acute care, and some studies have questioned whether they actually lead to any savings for CMS.

But perhaps most notably, the new bundled payment model rolled out by CMS in February 2018 gave primacy to hospitals and physicians, while skilled nursing facilities and home health agencies could not be episode initiators. Even without this stipulation under the Bundled Payments for Care Improvement Advanced (BPCI Advanced) initiative, for many providers, bundled payments have been a mixed bag. While 75% of 70 respondents to one survey said they helped improve quality, only 63% said they provided better care at a lower cost.

CMS and CMMI tend to prefer hospitals and physicians as leaders of bundled payment models, Nicole Fallon, vice president of health policy and integrated services at LeadingAge, told SNN. But when it came to the initial BPCI model, post-acute providers were the biggest participants, which made it frustrating when CMMI did not allow them to take the lead in BPCI Advanced, she said.

“They did say that post-acute providers can convene [the models],” Fallon noted. “While practically speaking, that works, if we think operationally, what hospital group or physician is going to let a post-acute provider take control of the money and decide where the gain-sharing goes? They’re going to say, ‘No, I’ve got this.'”

Hammel also commented on this phenomenon in the context of post-acute’s removal from the driver’s seat.

“Last year, the introduction of BPCI Advanced eliminated the opportunity for post-acute providers to be episode initiators,” she said. “While they can still be involved (such as being a preferred referral partner) their inclusion depends on hospitals, physician groups, and other providers’ willingness to partner and share risk.”

Not every post-acute provider is looking for the opportunity to take part in bundled payments as an episode initiator, Fallon noted. But being able to do so would be particularly helpful for those that have invested in changing care delivery patterns. And because so many of the people served live in nursing homes long-term, those facilities have some insight into the individuals that make them more effective in some ways for them to manage their care, she added.

But under the current system, cutting post-acute care out of the picture makes fiscal sense.

“When you look at [accountable care organizations] and bundled payments initiatives, a good chunk of the savings they will point to comes out of post-acute care, and at least part of the reason is that in the SNF setting, you are paid a per diem,” Fallon explained. “So every day you shave off a stay, that’s savings to the system.”

Bundled payments in general are the right direction for CMS to go, Fallon was quick to emphasize. But the rules that are currently in place make it challenging, and cutting revenue for SNFs will eventually lead to closures.

And while many post-acute providers have worked to adapt to the new models, all they are seeing for it is lost revenue and no tangible benefits.

“The gainsharing’s not happening, even though we’re making the changes,” Fallon said. “The perception is that the additional volume of business, that’s enough. But more volume at a lower cost is just more volume.”

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