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The Tangling of Bundled Payments

As the political debate over repealing and replacing “Obamacare” persists, the Affordable Care Act (ACA) itself set off a number of important changes across multiple agencies and industries – changes that seven years on, continue to shift and reshape.

Probably more than any other federal agency, the Centers for Medicare & Medicaid Services (CMS) has undergone the most significant shifts as it is the agency responsible for delivery and payment of healthcare for millions of patients across the country. 

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With the passage of the ACA, Congress created the CMS Innovation Center (CMMI) and charged it with testing “innovative payment and service delivery models to reduce expenditures . . . while preserving or enhancing the quality of care.” With that mission began the shift from a fee-for-service model to a valued-based reimbursement model. As a result, physicians and other healthcare providers have had to test a variety of different payment and service delivery models developed by CMMI and implemented by CMS. 

Of the multiple programs developed over the past seven years, the bundled payment model, called the Bundled Payments for Care Improvement initiative (BPCI), has been the most widely implemented as commercial insurers have been quick to offer bundled reimbursement programs. But the program hasn’t been without controversy because of CMS designating some bundled programs as voluntary, while making others mandatory. It is widely known that the new Health and Human Services Secretary Tom Price strongly opposes mandatory bundled payments and, in general, Republicans in Congress disfavor CMMI’s mandatory initiatives, as shown in a letter signed by 179 Republican members last September accusing CMS of overstepping its authority by imposing a mandate without Congressional approval. 

Consequently, it is not surprising that on March 21, CMS announced a delay in the implementation of its recent rule creating a mandatory bundled payment program for cardiac care and in the expansion of a major payment pilot, the Comprehensive Care for Joint Replacement (CJR), from July 1, 2017 to October 1, 2017. Effective dates for final rules on CJR also were pushed back from March 21, 2017 to May 20, 2017. 

If these delays reflect the priorities of the new administration, physicians should watch Secretary Price’s actions in this arena for any indication of a major new approach to bundled payments. Meanwhile, as bundled payment models become more widely implemented, they will likely shift to conform to the definition of advanced alternative payment models (APMs), as outlined in MACRA.

Click here for the CMS website.