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What Are Bundled Payments?

NEJM Catalyst
February 28, 2018
This article appeared in NEJM Catalyst prior to the launch of the NEJM Catalyst Innovations in Care Delivery journal. Learn more.
Bundled payments represent one form of alternative payment models (APMs) that are designed to move toward value-based care by incentivizing providers to advance coordination and efficiency of care while also improving quality and outcomes at lower costs. With bundled payments, the total allowable acute and/or post-acute expenditures (target price) for an episode of care are predetermined. Participant providers share in any losses or savings that result from the difference between this target price and actual costs.
Bundled payments, also known as episode payment models (EPMs), require participant providers to assume risk, as they must cover costs that go above the target price for an episode of care including those that arise from complications and hospital readmissions. On the upside, providers share in the savings if they keep costs below the target price while maintaining quality standards. Bundled payments are showing significant promise in improving care quality while at the same time bringing costs down.
 Episode of Care Definition
An episode of care involves the entire care continuum for a single condition or medical event, such as joint replacement or labor and delivery, during a fixed period. It includes all acute and post-acute care delivered by hospitals, physicians, skilled nursing facilities, and other providers participating in a care pathway. Other episodes of care commonly involved in bundled payments are:
Myocardial Infarction
Congestive Heart Failure
As these examples illustrate, some episodes of care represent a higher risk than others. Additionally, patients also represent different levels of risk based on age, behavioral factors, and comorbidities. For these reasons, bundles can be adjusted to reward providers who assume more risk.
Bundled Payment Models: Retrospective and Prospective Payment Systems
There are two basic types of bundled payment models: retrospective payment systems and prospective payment systems. In a retrospective payment system, payers retain a fee-for-service (FFS) arrangement and continue to compensate providers directly. But they also track total costs against the predetermined target price. If costs exceed the target price, then the payer reduces payments accordingly. If costs are lower than the target price, then providers share in the consequent savings.
In a prospective model, payers make a single lump-sum payment to a convener who then distributes payment to the various providers involved in the episode of care. As with the retrospective model, providers share in any losses or gains based on the predetermined target price.
CMS Bundled Payments for Care Improvement (BPCI)
First introduced at the Texas Heart Institute in 1984, bundled payments rose to prominence with the passage of the Patient Protection and Affordable Care Act (PPACA). This legislation led to the formation of the CMS Innovation Center which created the Bundled Payments for Care Improvement (BPCI) Initiative. Four bundled payment models were developed and piloted through this program between 2013-2017:
Figure 1
Four payment models under CMS’s BPCI Initiative
Four payment models under CMS’s BPCI Initiative
Medicare Bundled Payments 2018: CMS BPCI Advanced
At the end of November last year, the Trump administration canceled hip fracture and cardiac care bundles that were mandatory under the Obama administration. To reduce the burden on rural hospitals, they also significantly decreased the number of geographic locations from 67 to 34 where participation in the Comprehensive Care for Joint Replacement (CJR) payment bundle was required.
But in January 2018, CMS confirmed its commitment to bundles when it announced BPCI Advanced. Participation in the program is voluntary and involves a single retrospective bundled payment for a 90-day clinical episode duration.
These policies left healthcare leaders wondering about the future of bundled payments. But in January 2018, CMS confirmed its commitment to bundles when it announced BPCI Advanced. This new CMS bundled payment model includes twenty-nine inpatient and three outpatient episodes of care. Participation in the program is voluntary and involves a single retrospective bundled payment for a 90-day clinical episode duration. BPCI Advanced qualifies as an Advanced APM under MACRA’s Quality Payment Program to further entice physicians to participate with the additional Advanced APM monetary incentives.
Bundled Payment Success Strategies
One area where bundled payment models are showing great promise is in joint replacement procedures. Several providers demonstrated cost savings, particularly in post-acute care costs, under CMS’s CJR payment bundle. According to a JAMA study published in February 2017, CJR saved U.S. taxpayers $5577 or 20.8% per joint replacement care episode for 3942 patients.
Providers who have piloted bundled payment programs are having success in other areas as well. Here we outline nine strategies that have been gleaned from the experiences of early participants:
Physician Leadership Leverage the clinical expertise and experience of physicians throughout the entire care journey. Surgeons, hospitalists, and other specialists should stay proactive in decisions about patient recovery even after they have left the hospital.
Care Navigator or Coordinator Assign navigators to patients to assist them with post-discharge care in areas such as medication and care instructions. While many organizations fill this role with nurses, others are tapping non-licensed personnel to liaise with the care team and to help with non-clinical post-discharge activities such as filling prescriptions and getting to follow-up appointments. This additional support is proving cost and care effectively.
Consensus Building Develop consistent care pathways by gaining consensus from all involved providers regarding metrics, guidelines, and protocols as well as a system of governance that monitors and ensures compliance. Establishing on-going partnerships between acute and post-acute providers builds trust and reduces clinical and financial variations.
Early Mobility Get patients moving as early as possible after an acute care event. Mobility has long been shown to speed up recovery. It also reduces the length of stay at skilled nursing and inpatient physical therapy facilities and sometimes prevents the need altogether.
Mine Existing Data Use historical data to understand variation in patient care journeys and their subsequent outcomes to identify opportunities. What worked well? Where can inefficiencies be eliminated? Also, use predictive analytics to understand higher-risk patients who have comorbidities, sometimes referred to as “bundle breakers.”
Classify Episodes of Care Based on Risk Group episodes of care according to risk when negotiating target prices. For example, elective hip replacement patients represent lower risk than those with hip fractures, so bundles should be priced accordingly.
Technical Infrastructure Develop internal data systems as well as appropriate provider collaboration and information sharing tools. Or consider hiring third-party administrators such as tech companies or outside bundle conveners to do it for you. Having access to data across care teams and throughout the span of time for an episode of care offers unprecedented learning opportunities.
Reduce the Use of Skilled Nursing and Inpatient Physical Therapy Facilities When appropriate, send patients home by engaging the family in care. For patients with higher care needs, develop a strategy that prioritizes patient mobility and strives to reduce time spent in care facilities. 
Prepare Patients for Success Encourage patients to quit smoking, attend to their comorbidities such as diabetes, and address their social needs. Proactively educate patients and their families about what to expect and how to care for themselves post-discharge.
Bundled Payments: A Permanent Fixture in Health Care
With the promise of the early BPCI bundles, the government’s recently renewed commitment to these APMs, and the collective knowledge gained from early pilots, more and more health care leaders are exploring bundled payments’ potential for reward. In fact, according to McKesson and ORC International, payers are forecasting bundled payments to account for 17% of payments by 2021. What’s more, large ­employers who, along with their workers, are being crushed by high insurance costs, are directly negotiating bundle pricing. These are telling indicators that bundled payments will remain a key APM in value-based care strategies.

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Published In

NEJM Catalyst
February 28, 2018


Published in issue: February 13, 2018
Published online: February 28, 2018




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