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April 2017

Editor's Note: Bundles Bring Baggage
By Lee DeOrio
For The Record
Vol. 29 No. 4 P. 3

What health care program worth its weight hasn't fallen victim to a delay? Realistically, it's a foregone conclusion. That's why there was relatively little fuss raised when the Centers for Medicare & Medicaid Services (CMS) announced that the implementation of four Medicare bundled-payment initiatives was being pushed back three months to October 1. In fact, considering many of the program's details had yet to be worked out, most observers believe CMS made the right decision.

"The delay gives CMS more time to review details of the initiatives, gives participants more time to prepare for these models, and also may allow for payment periods to align with the calendar year," says Vicki Harter, vice president of care transformation at Caradigm. "While clear direction from the Trump administration is essential regarding value-based care, perhaps the delay will also allow input from a broader set of providers and other key stakeholders."

That additional input would be most welcomed, especially in light of the addition of hip fractures to the Comprehensive Care for Joint Replacement (CJR) bundled-payment program. "While the original CJR program focused on elective procedures, hip fractures present an entirely new conundrum," Harter says. "These events occur frequently among the most frail elderly in the Medicare population. Coordination of care, and management of both comorbid conditions and barriers to care that may have precipitated the fracture event become essential. Consequently, some providers believe that CJR should account for patient risk variance before hip fracture is added to the bundled-payment program."

Besides hip fractures, acute myocardial infarction, coronary artery bypass graft, and cardiac rehabilitation join the fray, adding more potential headaches for health care organizations. "It requires increased accountability for hospitals to identify and provide coordination for postacute care," Harter says. "Those hospitals that chose to engage in the model will have great responsibility. … Hospital-provider relationships will become key across the continuum, resulting in continued narrow network contracting."

Based on results from the Center for Medicare & Medicaid Innovation's voluntary bundled-payment programs, voluntary programs have been found to be more effective than mandatory programs in improving care. Fortunately for the industry, this falls in line with the thinking of newly christened Health and Human Services Secretary Tom Price, MD. "If Dr. Price's preference to eliminate mandatory bundles becomes central to the program, outcomes may be enhanced, but selection of bundles for participation will require considerable decision making on the part of the provider community," Harter says.