Future Bundled Payment Programs to Improve Care Transitions and Collaboration Across Patients’ Care Journey

Article Highlights

• The future expansion of bundled payment programs.
• Achieving greater participation by specialists in bundled payment programs.
• The goal of improving care transitions.
• Creating solutions across the care continuum.

CMS is asking for feedback to create a future episode-based payment model seeking feedback regarding a potential new episode-based payment model that would be designed with a goal to improve beneficiary care and lower Medicare expenditures by reducing fragmentation and increasing care coordination across health care settings. CMS expects this episode-based payment model to be implemented no earlier than 2026, ensuring participants have sufficient time to prepare for the model.

In this next model, CMS is building on care improvements to better align episodic and longitudinal, population-based incentives to strengthen communication, collaboration, and coordination across providers at all points of a patient’s journey through the health care system. This will be achieved through design features such as considering a shorter, 30-day episode to support coordination, while limiting overlap.

CMS Takes Lessons from Previous Bundled Payment Models

The Innovation Center is utilizing lessons learned from their experience with the Bundled Payments for Care Improvement, Bundled Payments for Care Improvement Advanced, and the Comprehensive Care for Joint Replacement models to design and implement a new episode-based payment model focused on accountability for quality and cost, health equity, and specialty integration.

6 Fundamental Components

CMS is requesting input on a broader set of questions related to care delivery and incentive structure alignment and six foundational components:

1. Clinical Episodes
2. Participants
3. Health Equity
4. Quality Measures, Interoperability, and Multi-Payer Alignment
5. Payment Methodology and Structure
6. Model Overlap

Another goal for episode-based payment models is to:

• Improve care transitions for the beneficiary; and
• Increase engagement of specialists within value-based, accountable care.

Through this next model, CMS will build on those care improvements to better align episodic and longitudinal, population-based incentives, thereby strengthening communication, collaboration, and coordination across providers at all points of a patient’s journey through the health care system. This will be achieved through design features such as considering a shorter, 30-day episode to support coordination while limiting overlap.

Design features such as considering a shorter, 30-day episode can support coordination, while limiting overlap.

To help CMS ensure all accountable entities provide patients with the highest value care, the organization seeks input on the following questions:

• How can CMS structure episodes of care to increase specialty and primary care integration and improve patient experience and clinical outcomes?
• How can CMS support providers who may be required to participate in this episode-based payment model?
• How can CMS ensure patient choice and rights will not be compromised as they transition between health care settings and providers?
• How can CMS promote person-centered care in episodes, which includes mental health, behavioral health, and non-medical determinants of health?
• How can CMS support multi-payer alignment for providers and suppliers in episode-based and population-based models?
• For population-based entities currently engaging specialists in episodic care management, what are the key factors driving improvements in cost, quality, and outcomes?
• How does the nature of the relationship (that is, employment, affiliation, etc.) between a population-based entity and a specialist influence integration?
• What should CMS consider in the design of this model to effectively incorporate health information technology (health IT) standards and functionality, including interoperability, to support the aims of the model?
• How can CMS include home and community-based interventions during episode care transitions that provide connections to primary care or behavioral health and support patient independence in home and community settings?

Which Organizations Are Using Bundled Payment Models?

Centers for Medicare and Medicaid Services

CMS is currently testing a variety of bundled payment models for providers caring for Medicare fee-for-service beneficiaries. The types of episodes included in CMS’s bundled payment models span surgical procedures and medical care, including oncology. As of early 2023, provider participation in most CMS models is voluntary rather than mandatory.

Medicare Advantage Organizations (MAOs)

MAOs use bundled payments for in-network providers caring for members enrolled in their Medicare Advantage products. A provider’s participation in an MAO’s bundled payment arrangement is typically voluntary. Because of the similarities in the demographics of individuals covered under Medicare fee-for-service and Medicare Advantage, MAOs may use CMS’s episode specifications as a starting point for how their bundled payment arrangements define an episode of care.

Commercial Health Plans

Commercial health plans use bundled payments for in-network providers caring for members enrolled in their commercial products (e.g., individual and group, fully insured and self-insured). Provider participation in a commercial health plan’s bundled payment arrangement is typically voluntary.

Medicaid Organizations

Some state Medicaid agencies have implemented bundled payments for providers caring for Medicaid beneficiaries and/or members enrolled in a plan offered by a Medicaid managed care organization. For example, Arkansas,² Ohio,³ and Tennessee⁴ have each developed programs requiring providers to participate in bundled payments spanning multiple specialty categories, and Colorado⁵ has developed a voluntary program focused on maternity episodes.

Request for comments in the Federal Register (request PDF).