As medical payments shift toward value-based, rather than volume, the Centers for Medicare and Medicaid Services (CMS) looks to implement more bundled payments for longer episodes of care and more clinical services, according to a viewpoint published Dec. 17 in the Journal of the American Medical Association.

Rahul Rajkumar, MD, JD, et al., of CMS, state that bundled payments create “efficient, coordinated, and... high-quality” care by linking payments for services and making a single organization responsible for the majority of patient care received during an episode. In order to broaden the scope of bundled payments, the CMS Innovation Center has created Bundled Payments for Care Improvement (BPCI), the Comprehensive Care for Joint Replacement (CJR) Model, and the Oncology Care Model (OCM).

Since October 2015, CMS has been testing the effectiveness of the BCPI model as a payment strategy, allowing each of the 1551 participating organizations to choose episodes of care “triggered by a hospitalization for one or more of 48 different medical and surgical conditions.” Rajkumar et al., note that early data from the test organizations show a tendency toward less costly home health care, with reduced rates of 30-day readmission and hospital length-of-stay. The CJR model, for episodes of care hospitalization for hip or knee replacement, and the OCM, for patients who receive chemotherapy for cancer, will both begin later in 2016.

In introducing these new bundled payment models, CMS has laid out several guiding principles specific to design and implementation. Accordingly, related care during an episode is broadly defined in order to “encourage clinicians and health care organizations to be accountable for the full spectrum of services a patient receives.” Further, successful tests of the new bundled payment models could allow for expansion of existing alternative payment models, as well as allow multiple bundled payment models to co-exist. Finally, the technical side of bundled payment models will evolve as CMS learns more about the outcomes of the models. Rajkumar et al., state that “the quality measurement strategy must also evolve to incorporate shared decision making, patient-reported outcomes and clinical appropriateness.”

Learn more about alternative payment models and the shift from volume to value-based care on ACC’s Health Policy Issue Center. 

Keywords: American Medical Association, Centers for Medicare and Medicaid Services, U.S., Decision Making, Episode of Care, Health Expenditures, Health Policy, Medicaid, Medicare, Patient Care Bundles, Patient Outcome Assessment, Patient Readmission

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