Pilot Resources for CMMI's Bundled Payments for Care Improvement Initiative
Overview
The Center for Medicare & Medicaid Innovation's (CMMI) Bundled Payments for Care Improvement initiative pilot is a bold, broad and flexible approach to moving the country away from fee-for-service and into value-based payment. We've assembled information and tools to help prospective pilots take part in the initiative.
CMS's CMMI Bundled Payment Info and Application Page
There are several important features to note about this pilot and considerations for both providers and private sector payers. In addition, there are four models that providers can participate in. Model 1 is, in HCI3's opinion, too narrow. We are only providing resources for Models 2 through 4.
Model 2:
This model is the most comprehensive of the four and includes the acute and post-acute phases of an episode. The episodes are anchored by a DRG and can have a time window as short as 30 days and as long as the applicant selects. The length of the time window affects the amount of discount to go back to CMS. Windows of 90 days or less require a 3% discount, and windows greater than 90 days require a 2% discount.
The applicant is expected to assemble a team, select the episodes of care, analyze data Medicare provides, and then develop an application that will include details on the episode or episodes selected, and the fixed discounted price per episode. During its evaluation, CMS will favor applicants participating in similar private-sector efforts. Potential Applicants can use our "freeware" analysis and reporting tools to analyze Medicare part A and B claims to select episodes and calculate and episode price.
CMS will not prospectively pay the agreed upon price, but will pay all claims fee-for-service and perform a back-end reconciliation. If the aggregate sum results in lower costs than agreed to, then CMS will write a check for the difference to the applicant. If the aggregate sum results in higher costs than agreed to, then the applicant will write a check to CMS.
Model 3:
This model follows Model 2 except that it only includes the post-acute phase of the episode. The episode of care begins at the initiation of post-acute care within 30 days of discharge from the inpatient stay. Initiation of post-acute care is defined as an admission to a Skilled Nursing Facility, Long Term Care Hospital, Inpatient Rehab Facility, or Home Health Agency. It ends no sooner than 30 days after the initiation of the episode.
Model 4:
This model is similar to the current Acute Care Episode demonstration. The applicant has to be a hospital, and the hospital must have an agreement with surgeons/ other physicians to pay them their portion of the bundle. Bundles are all anchored on a DRG and have a time window equal to the hospital stay. Related readmissions and their associated Part B services are included in the post-acute phase, which must be a minimum of 30 days.
These bundles will be paid in one lump sum when the episode is triggered, and the payment will be made to the hospital, which is then expected to make payments for the Part B claims.
