New bundled payment model may leave SNFs at disadvantage

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Consultant Anne Tumlinson says some LTC providers are disappointed over a lack of opportunity
Consultant Anne Tumlinson says some LTC providers are disappointed over a lack of opportunity

A new voluntary bundled payment model announced this week doesn't focus on cost-saving innovations in the long-term care setting and limits benefits for those providers, observers said Wednesday.

The Centers for Medicare & Medicaid Services Center for Medicare and Medicaid Innovation announced the long-awaited Bundled Payments for Care Improvement Advanced, or BPCI Advanced, on Tuesday.

The new model includes 32 clinical episodes  — down from 48 — ranging from joint replacements to coronary intervention. But post-acute organizations can only participate through financial partnerships with other providers in the new version.

“This initiative effectively sunsets the SNF setting as the location for initiating an episode and taking risk as a participating provider,” Anne Tumlinson, CEO of Anne Tumlinson Innovations told McKnight's.  “That was the original BPCI Model 3, and a lot of providers are disappointed that they won't have the opportunity to continue in that role.”

The new model is more like the previous BPCI Model 2, in which hospitals or conveners took on risks and limited partnerships, referring their patients to home healthcare or shortening skilled-nursing lengths of stay.

Theoretically, Tumlinson notes, bundled payment participants still can share savings with post-acute care partners, but it hasn't often happened in the original models.

“I would bet (it) won't happen this time around,” Tumlinson said, noting that physician groups are unexplored territory because they didn't participate originally. Tumlinson's Washington, D.C.-based research and consulting firm advises healthcare providers, payers and investors on post-acute and long-term care delivery and financing.

CMS says bundled payments encourage providers to better coordinate care and innovate. Instead of paying for individual services, bundled payment models allow participants to earn extra payments if high-quality care for a beneficiary's entire episode of care comes in under a predetermined spending target.

But observers say details of the new program could discourage some past participants from joining the cohort starting this October.

For instance, participants in this new program can choose which episodes they want to bundle care for, but they are then locked in until 2020. During a previous program, providers could drop out as desired.

Even some hospitals that had previous success with bundles are “taking a been there, done that” approach and looking instead at payment alternatives such as ACOs, said Jonathan W. Pearce, CPA, principal of Singletrack Analytics, LLC.

Typically a proponent of bundles, Pearce blogged Wednesday about questions surrounding the new model.

Why, for example, were joint replacements maintained in the in-patient episode category, rather than shifted to outpatient services as care trends dictate?

“By not including it (under the outpatient heading) in a plan that's going to run five years, you're going to lose a lot of episodes,” Pearce notes, adding that SNFs will miss out on gain-sharing for those procedures.

The voluntary bundle is the first introduced since the Trump administration canceled two mandatory bundles late last year.

Though former Health and Human Services Secretary Tom Price, M.D., criticized mandatory bundled payment programs, nominee Alex Azar said he was open to them during his confirmation hearing Tuesday.

Like the ongoing Comprehensive Care for Joint Replacement Model, incentives in this model are tied to quality indicators such as hospital readmission and advance care planning.

There is a silver lining, Tumlinson said, for SNFs with enough scale and enough bravado to get “way out of their comfort zone.”  

“There's nothing to prevent SNFs from being conveners, if they can sign up hospitals and/or physicians as partners,” she said. “I'm really excited about this avenue for some of the SNF organizations that are already taking risk for the long-stay residents through the Medicare Advantage program.”

The new bundle program will run through Dec. 31, 2023, with each episode reviewed for inclusion annually starting in 2020.

Applications must be submitted by March 12.