The bundled payment market expanded significantly in 2019 and will continue to do so in 2020. Growth was primarily driven by industry pressure to deliver value-based care through alternative payment models (APMs). The most recent numbers show that over 35% of US healthcare reimbursements 通过APMs流动比三年前增长了52%. This evolution paved the way for bundled payments, a relatively low barrier-to-entry APM model. For 付款人s and providers lacking experience in such value-based payment models, “episodes of care” are less complex compared to their ACO and full-capitation counterparts, which has contributed significantly to bundled payments’ rise in popularity.
增长也受到了推出 Bundled Payments for Care Improvement (BPCI) Advanced, a voluntary CMS program that allowed hospitals and physician groups to select specific episodes of care for participation. 值得注意的是, the program offered participation in 35 clinical episodes that spanned 8 service lines and included medical issues, 慢性疾病, 还有外科手术. To date, the program counts 1,010 hospitals and 1,031 physician groups as participants. The second cohort of BPCI Advanced began on January 1, 2020.
Based on CMS activities and our observations throughout 2019, we anticipate four key bundled payment trends to look for in 2020.
1. Mandatory participation in bundled payment programs is likely.
In 2019, CMS announced a policy shift regarding mandatory bundled payment programs. Historically a staunch advocate of voluntary payment models, HHS Secretary Alex Azar said the administration would “revisit” mandatory programs that had previously been abandoned. His announcement was followed by the release of a Government Accountability Office (GAO) report that outlined the advantages of mandatory bundled payment programs. 具体地说, the GAO concluded that mandatory models are more likely to encourage the transition from traditional Medicare fee-for-service to value-based care models among providers that may be reluctant to make the change on their own. 进一步, mandatory models allow CMS to collect more reliable performance data and test models that have greater financial risk.
下面这些事件, CMS proposed a new bundled payment program for cancer patients known as the Radiation Oncology (RO) Model. The program will be mandatory for all providers in designated regions and will include significant downside risk. Although CMS’s original intention was to begin the program in the first half of 2020, it is likely to be delayed due to stakeholder pushback. 与此同时宣布, CMS proposed two voluntary bundled payment programs related to kidney care, 哪些被推迟到2021年.
CMS对强制性捆绑支付的立场是明确的, and we expect similar programs to be announced later in 2020. Provider organizations preparing for mandatory programs should focus initial efforts on data analytics, bet8网站备用参与和协调, 以及急性期后护理协调.
2. 站点中立支付将变得越来越普遍.
Site-neutral payments have been a contentious topic over the past year. 尽管联邦法院否决了这项政策, CMS and the Trump administration elected to move forward with the decision to pay doctors the same amount for basic visits, regardless of whether the visit occurs in a hospital outpatient facility or a regular physician office. CMS estimates that the policy will cut federal spending by $800 million in 2020.
Site-neutral payments are now being incorporated into bundled payment models. CMS explicitly identified site-of-service payment differentials between freestanding centers and hospital outpatient departments (HOPDs) as one of the major drivers for implementing the RO Model. Payment calculations in the model will now be based on the lower of the two settings regardless of where the radiotherapy treatment is performed. 进一步, 在BPCI高级计划下, CMS implemented site-neutral payments for major joint replacements of the lower extremities. 最后, commercial 付款人s have also started implementing site-neutral payments; in 2019, Blue Cross Blue Shield of North Carolina initiated site-neutral bundled payments for hip, 膝盖, 肩关节置换.
2020年, 我们期待政府的纳税人, 商业保险公司, and employers to continue to adopt site-neutral payments in bundled payment models. 此结构对齐提供程序, 付款人, and patient interests by removing incentives to provide more complex treatments or select more expensive sites of care.
3. 与供应商组织相比, 付款人s and employers are driving the shift toward bundled payments.
过去一年, large commercial 付款人s have taken significant initiative to develop and launch bundled payment programs. Many of these 商业保险公司—like UnitedHealthcare and Horizon Blue Cross and Blue Shield of New Jersey—are increasingly focused on direct partnerships with physician groups as episode initiators. Physicians play a critical role in patient management and care coordination under an episode-of-care model. 承包 directly with physician groups allows 付款人s to appropriately incentivize them for improved outcomes and reduced cost.
进一步支持捆绑支付计划, technology and analytics companies have begun launching products to help insurers define and price episodes of care across various service lines. 具体地说, software tools will assist 付款人s with the technical aspect of claims adjudication in a bundled program. The emergence and growth of analytics-based organizations will further expand the commercial market in 2020.
而市场在持续增长, providers who are ahead of the value-based curve will be the most successful. Provider organizations that recognize the value of bundled payments will likely be able to work in partnership with 付款人s and structure mutually beneficial arrangements that align with their strategic priorities and initiatives.
4. Substance use and behavioral health bundles will emerge.
Bundled payments for behavioral health services are a relatively new concept, and design of best-in-class models remains a work in progress. 然而,对于2020年,我们注意到两个关键的新兴趋势:
- 发展药物使用捆绑付款
- Bundled payments as a vehicle for primary care and behavioral health integration
Both of these developments significantly increase patient access to behavioral health services and ensure better patient outcomes.
药物使用捆绑付款
The majority of patients seeking treatment for substance use will do so in a residential facility (as opposed to hospitals or outpatient facilities). 传统上, services provided at residential facilities have not been fully reimbursed by commercial or government 付款人s, and patients must pay for room and board out of pocket (medical treatment is usually reimbursed). 进一步, 出院后护理通常是孤立的, 不协调的, 管理不善, which greatly increases the likelihood of a patient’s relapse or hospital admission. 事实上,几乎 50%的患者复发 在他们出院后的第一年.
Bundled payments offer a solution: when treated within the context of a defined program with comprehensive postdischarge services, patients with substance use disorders are more likely to achieve lasting sobriety. 纳税人 and providers interested in developing substance use disorder bundles should ensure follow-up care addresses not only the patient’s health but also their family relations and employment, 为了继续保持清醒. Providers that are first to market with commercial 付款人s or employers are bundling care for up to a year postdischarge (from a residential treatment facility). 对于更严重的病例, arrangements may include discounted rates for patients who require an additional stay in the residential treatment center during the one-year postdischarge period. 随着这些bet8娱乐的报销增加, providers can achieve financial sustainability and increase access to behavioral health services.
行为健康整合的捆绑支付
In addition to substance use disorder bundled payments, 付款人s and providers are developing episodes of care for patients with serious and persistent mental illness (SPMI) such as major depression, 双相情感障碍, 和精神分裂症. 比物质使用障碍更复杂, SPMI requires a team of qualified multidisciplinary providers to work in a highly coordinated manner. 具体地说, 这些套餐包括初级保健, 药店, 以及其他医疗bet8娱乐, 除了行为健康. 过去一年, we have seen 付款人s move away from traditional carve-outs for behavioral healthcare as they have begun to recognize the value of integrating services in treating complex mental illnesses. 通过团队决策, integration ensures better patient outcomes and reduces the likelihood of an emergency department visit or hospital admission. 包容 of 药店 services is especially important, as medication plays a significant role in the routine care of SPMI patients.
Bundled payments offer a vehicle for 付款人s to integrate services, 加强护理协调, and manage costs for SPMI patients; however, 由于这些束的复杂性, 付款人-provider contracts may vary greatly from one arrangement to another. 例如, large employers often contract directly with the primary care provider and allow that physician to “quarterback” all care required over the course of the episode. In contrast, 商业保险公司 may prefer to contract with each participating provider separately. 不管最后的安排如何, 付款人s and providers must specify the services to be performed by each provider. A primary care provider may offer certain services at a lower cost than a psychiatrist or other behavioral health specialist. The model must also be designed to ensure that services are not duplicated by each participating provider.
一个共同的线索
The two types of behavioral health bundles described here have one thing in common: they aim to provide definition and structure to services that are currently ambiguous and managed ineffectively. The primary goal of behavioral health episodes of care is not to reduce spend but rather to improve patient access and outcomes. 随着这些程序变得越来越普遍, we will see more commercial 付款人s and employers embrace bundled payments for behavioral health.
捆绑支付将继续增长
Throughout 2020, the bundled payment market will continue to expand. 增长将由新的CMS项目决定, 创新支付结构, 新兴的bet8娱乐线路. 质量和价值驱动型组织, 谁也愿意承担适当的风险, are most likely to succeed under bundled payments and will find themselves advancing further along the value-based care-delivery continuum.
2020年1月21日发布