Toward Accountable Payment

CMMI hints at new outpatient bundled payment pilot

by Rob Lazerow

Last week, CMS’s Center for Medicare and Medicaid Innovation (CMMI) issued a request for information (RFI) on a potential new bundled payment program, introducing two important evolutions in the use of bundled payments.

First, the RFI signals Medicare’s interest in expanding the application of bundling from inpatient to outpatient care. To date, Medicare’s bundled payment programs—including both the Acute Care Episode Demonstration and Bundled Payments for Care Improvement (BPCI) Initiative—have primarily focused on inpatient care.

Second, the RFI shifts the focus of bundling from institutions to individual physicians. BPCI, for example, is structured around use of hospitals and post-acute services. CMMI’s new RFI focuses specifically on specialty practitioners, noting that one objective of a future outpatient bundling pilot would be "to improve the effectiveness and efficiency of specialty care, in part by clarifying the specialist practitioner’s clinical role."

CMMI is currently requesting feedback on the potential development of two different types of outpatient specialty bundles: procedures and complex chronic care. CMMI appears open to bundled payment proposals for a wide range of specialty services except for medical oncology, as a separate model is under development for medical oncologists.

Model for outpatient specialty procedures

CMMI is interested in developing a bundled payment model for outpatient specialty procedures. Under current bundling programs, including BPCI, outpatient surgeries and procedures are typically exempt from the programs. As a result, inpatient orthopedic surgery or cardiac catheterization could be bundled right now, but the same procedure performed on an outpatient basis could not.

CMMI notes interest in testing bundling for both surgical procedures and nonsurgical treatments, highlighting colonoscopy, cataract surgery, and radiation therapy as examples of potential bundling opportunities.

CMMI seeks feedback on a range of topics specific to outpatient procedural bundling, including:

  • Types of outpatient procedures and clinical conditions most appropriate for bundling
  • Definition of the parameters of outpatient episodes
  • Services that should be included within a given outpatient episode
  • Factors influencing provider interest in bundling
  • Quality metrics to ensure safe and effective care delivery
  • Challenges of implementing an outpatient procedural bundling
  • Opportunities to improve quality and reduce expenditures within a given procedural bundle

Model for complex, chronic disease management by specialists

CMMI also wants to test use of bundled payments for specialists treating patients with complex chronic diseases:

"CMS is considering development of a model that would incentivize specialists to more efficiently manage the care provided to beneficiaries with complex or chronic medical conditions over the period of time that corresponds to the specialty practitioner’s long-term involvement with managing the beneficiary’s care."

This bundled payment model would be distinct from the new payments for chronic care management slated to begin in 2015 through the Medicare Physician Fee Schedule.

CMMI seeks feedback on a range of topics pertaining to bundling for complex chronic care, including:

  • Definition of chronic care management bundles
  • Health conditions most appropriate for chronic care bundling
  • Services that should be included within a given chronic care bundle
  • Considerations for attributing patients for chronic care bundling
  • Factors influencing provider interest in bundling
  • Quality metrics to ensure safe and effective care delivery

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Meet the Author

Rob LazerowRob Lazerow
Practice Manager
Health Care Advisory Board