How Hospitals, Physicians, and Others Can Get Organized to Participate in CMS’ Bundled Payment Pilot

Seeking to improve patient care through payment innovation, the federal Centers for Medicare & Medicaid Innovation (CMMI announced its Bundled Payments for Care Improvement initiative in August. Model 2 of this initiative offers a fairly flexible approach to hospital-physician collaboration around DRG-based episodes. There can be as many or as few episodes as the applicants prefer, and they can be as broad or narrow in scope as the parties choose. Collaboration with other types of providers will be necessary to manage care effectively, but to what extent will depend on the clinical conditions the episodes address.

For this article, we will discuss provider-based scenarios first, including how this initiative affects physicians and hospitals, other providers, and then its relationship to Stark and antikickback issues. See the sidebar for a discussion of how CMMI also has opened the door to a role for Conveners and Convener/Facilitators.

About the Author: Alice G. Gosfield (info@gosfield.com) is a lawyer and founder of Alice G. Gosfield & Associates, P.C., in Philadelphia. Her entire legal career has been restricted to health law with an emphasis on representation of physicians and their group configurations and a focus on non-institutional reimbursement including Medicare; managed care; fraud and abuse compliance and avoidance; medical staff issues, utilization management, and quality issues. She is HCI3’s board chair.

Editor’s note: In this article, we offer a presentation of scenarios and issues that are possible under CMMI’s Model 2 of the Bundled Payment Initiative. Readers should be aware that this article is not legal advice. For legal advice, readers should consult a knowledgeable health care attorney.