The National Association for the Advancement of Orthotics and Prosthetics (NAAOP) released a webcast during which NAAOP General Counsel Peter Thomas, JD, discusses the concept of bundling. A summary follows:
Bundling is sweeping across the Medicare program and will eventually have significant implications on O&P. The secretary of the U.S. Department of Health and Human Services (HHS) recently announced that by 2018 50 percent of Medicare patients will be part of alternative payment models (APMs) rather than the fee-for-service (FFS) program. Bundling is considered an APM. There are many forms to bundling, and the Centers for Medicare & Medicaid Services (CMS) is doing its best to accelerate this trend.
Bundled Payments for Care Improvement (BPCI) Initiative: The BPCI Initiative is situated under the Center for Medicare and Medicaid Innovation (CMMI). This program essentially experiments with APMs and numbers over 1,500 different models currently. Hospitals and hospital systems across the country have entered into arrangements with CMMI to provide care for certain patients with particular conditions outside of the FFS payment system. In many instances, these models establish certain quality indicators, cap payments, and reward providers who save money (compared to the FFS payment system) by sharing the savings with them. The intention is to study different methods of Medicare payment and make permanent those that are successful in improving quality and decreasing cost. Although this program has been under way for several years, there is little public information that describes which programs are most successful and which have failed.
Mandatory Bundling: Late last year, CMS issued a proposed rule to establish a mandatory bundling program for hip and knee joint replacement patients in many cities across the country. Known as the Comprehensive Care for Joint Replacement (CJR) bundled payment system, this program took effect April 1. Much like the BPCI programs, the CJR model establishes quality indicators and compares expenditures of a joint replacement episode of care to the cost of similar care under the FFS program and rewards providers who provide that care more efficiently. Because the program is so new, there is no real information that evaluates patient outcomes or whether savings are being achieved. This is the first mandatory bundled payment system under the Medicare program and serves as a template for other mandatory bundling programs. In fact, CMS recently announced a proposed rule to similarly bundle cardiac care. That same proposed rule expanded the number of conditions under the CJR bundling payment system.
There are many other forms of bundling as well, including Accountable Care Organizations (ACOs), Shared Savings Programs, and even managed care arrangements under the Medicare Advantage Plan program. In short, bundling is here to stay, and the O&P profession must carve a path into bundled payment systems to ensure continued patient access to quality O&P care. Unfortunately, this path is not clear. Bundled payment systems are typically time limited, usually a 90-day episode of care. For instance, patients with new amputations would likely be outside of the bundled payment episode once they are fully ready for a definitive prosthesis. This may also be true, though to a lesser extent, with custom orthoses. But the referral to a particular provider may very well be established within that initial 90-day window. Therefore, O&P practices across the country must figure out how their local market is reacting to bundling and engage hospitals, health systems, managed care organizations, ACOs, and other bundled payment entities to find their rightful place in these alternative payment models.