APM Issue Brief: Preparing for Bundled Payment Models: 7 Steps for Success

February 20, 2018

As the Quality Payment Program (QPP) comes into full force and the shift toward a value-based health care system continues, it is crucial the clinicians and practice administrators posture their practices to successfully implement bundled payment models.

Bundled payment models promote improved outcomes, higher quality and increased coordination of care for Medicare beneficiaries by requiring participants to assume financial and performance accountability for an entire episode of care, as opposed to separate individual procedures.

Existing bundled payment models include the Centers for Medicare and Medicaid Services' (CMS) Bundled Payments for Care Improvement (BCPI) initiative, concluding in 2018, CMS's new voluntary bundled payment model, Bundled Payments for Care Improvement Advanced (BPCI Advanced), and private payer bundled payment contracts. This model is intended to qualify as an Advanced Alternative Payment Model (Advanced APM) under QPP, which means qualified participating clinicians will receive a 5 percent payment bonus and exemption from reporting under the Merit-based Incentive Payment System (MIPS).

  1. Analyze your current performance. Whether you work in a hospital, an academic medical center, a single specialty or multi-specialty practice, analyzing your current Cost and Quality performance for your bundle will provide a necessary foundation of information. It is important to understand the underlying reasons for your current performance in terms of readmission rates and hospital acquired infection rates.
  2. Assess your current care pathway. Seek areas of improvement within your current care pathway. Understand the needs of your local patient population. Identify areas in your current care pathway where care can be coordinated better and more efficiently.
  3. Enhance care management functions and care coordination strategies. Managing episodes of care requires a team-based approach. Think strategically about the combination of clinicians and administrators that can assist with efficient and effective transitions of care and appropriate follow up after hospitalization during the span of the day episode. Consider rearranging your staffing model to include nurse navigators, as many participants who have been successful in the Bundled Payments for Care Improvement Acute Myocardial Infarction (AMI) and Coronary Artery Bypass Graft (CABG) episodes have relied heavily on a care team that includes nurse navigators. Additional best practices for success include:
    • Ensure a communication pathway between primary care physicians and the cardiovascular care team is in place. Referral management is critical to ensuring patients are appropriately transferred to the care team responsible for managing the patients within the episode for AMI and/or CABG at the right time.
    • Organize daily "huddles" for the care team to discuss patient challenges and approaches to solve them.
    • Ensure a point of contact (possibly a nurse navigator) is available to interact with the patient throughout the care pathway, and involve the patient in decision-making when appropriate.
    • Implement an effective triage plan for transitioning patients into post-acute care facilities. This can require additional administrative care planning processes.
    • Establish a plan for medication adherence and physical maintenance, communicate the plan to the patient and caretakers and provide opportunities for shared decision making along the way.
    • Ensure continuous monitoring of cost utilization and performance on quality metrics by implementing regular checks for areas of improvement.
  4. Map out your new and improved care pathway. Incorporate effective care management strategies for patients included in the new bundled payment model. If the model includes the acute and post-acute care (PAC) phase, ensure each phase allows for continuous communication and collaboration. Consider embedding nurses in post-acute care facilities to ensure safe and efficient follow up care delivery.
  5. Understand risk scores and risk management. Understand the care needs of your patient population ages 65 and above that have AMI and/or CABG. Risk adjustment and management is critical for this patient population.
  6. Partner more effectively with post-acute care facilities. There are strict rules that prevent clinicians from directly telling patients which PAC facility to choose. However, explaining partnerships in place and related benefits can assist the patient with choosing the PAC facility that is the best fit. Administrators, clinicians and post-acute care facility staff must work together to ensure there is a plan for communication and appropriate follow up for all patients within the episode that are transitioned to post-acute care facilities in the area.
  7. Understand the plan for distributing gainsharing payments. Clinicians should be aware of gainsharing and reconciliation payment arrangements set up through value-based contracts by hospitals they are either employed by or contract with.

Last updated Jan. 29, 2018.