Healthcare professionals are continuing to evaluate the progress of bundled payments as a way to manage the care received by patients.

The Centers for Medicare & Medicaid Services (CMS) launched Bundled Payments for Care Improvement (BPCI) in 2013. The program “changed the fundamental payment for care delivery from a prospective system to one dependent on cost and quality outcomes” while also driving physician and post-acute care provider behavior, explains Beverly Cunningham, MS, RN, ACM, partner and consultant at Case Management Concepts in Tulsa, OK.

Assume Risk to Improve Outcomes

Cunningham says that with the advent of changes in discharge planning requirements in recent years, case management departments must be staffed appropriately to minimize delays.

“The answer to that is bedside rounds every day when the physician, the nurse, the case manager, and the social worker are available,” says Cunningham. “At bedside rounds, the team can give the patient the plan and their estimated day of discharge. That way, there’s a one-time discussion. That’s how you keep the patient in tune with what’s going on.”

BPCI, she says, started out as a voluntary program with several diagnoses for providers to assume “a little bit of risk.”

“By assuming risk, they improve outcomes,” says Cunningham. “Then the provider increases their revenue and provides better outcomes for patients as well. When the risk goes to you, you begin to look at how you can more effectively manage patients while achieving the optimal outcomes.”

She notes that BPCI started out with four types of initiatives, with providers identifying which group they would be in.

“The CMS really had not allowed the BPCI initiatives to run their course,” says Cunningham. “They decided that they would take lower extremity joint replacement and make those mandatory bundled payments. In doing that, they selected geographical areas where any hospital in that area would have mandatory bundled payments.”

The program, she says, was successful in many hospitals in those 67 mandatory geographic areas, with a focus on hip and knee replacements for patients with Medicare Part A and Part B.

“It’s a five-year program where the first year, there’s no payment reduction at all,” she continues. “As you go through the remaining years, that’s when you have the payment reduction or the increase in payment. They were extremely specific in how they would pay and how they would evaluate. It’s very complex, but in order to receive additional payment, you had to meet certain criteria. It really incentivized providers to be organized in the care of these patients.”

“Commercial and state payers alike adopted bundled payment programs,” adds Cunningham. “Ohio, for example, introduced 10 mandatory bundles in 2015 with a plan to expand to an additional 20 episodes of care in 2019.”

Cunningham says hospitals began identifying the most cost-effective place after discharge from the hospital to ensure optimal outcomes for patients.

“That’s when they began to identify that if they increased the complexity of care provided by home care, they could bypass the skilled nursing facility and/or acute rehab,” she says.

Cunningham says CMS expanded the mandatory model with additional diagnoses and procedures in 2016. However, in early 2017, the expanded mandatory model was canceled, and the number of hospitals in mandatory geographic areas decreased from 67 to 33, she says.

The new and voluntary Advanced BCPI Model was introduced in November 2017. The program includes procedures, medical diagnoses, and outpatient episodes.

“Many hospitals have evaluated collaborating with the CMS in many, or all, these bundles,” she says. “As a result, 832 hospitals are participating in this new bundle initiative.”

Cunningham notes that at skilled nursing facilites, patients are at risk for readmission, infection, and falls, and there is a higher sick population at such facilities.

“That increases the cost of care,” she says. “It’s a bad outcome for the patient, it’s not optimal, and it increases your cost. For the appropriate patients, they’re providing appropriate care in home as opposed to transferring to a skilled nursing facility if it’s not needed.”

CMS did not expect that the majority of total knee replacements would be performed as outpatient procedures, Cunningham says.

“The government added more bundled payments and increased the number of diagnoses that would fall under bundled payments,” she says. “That changed the kind of patients that were in the mandatory program. Hospitals were really working diligently to figure out how they would manage patients when they had no idea what was going on with the patient before admission.”

Under that system, she says, there was no plan of care in place because there was no patient at all.

“Planning starts on the day of admission, but you’re kind of behind the eight ball on that, and that increases your cost,” says Cunningham. “It requires adequate staffing and effective focus by everyone in the healthcare team.”

She says when a new Department of Health and Human Services secretary was appointed, mandatory bundled payments stopped, thus opening the door for voluntary payments.

“Right now, where we sit, there’s a whole list of bundled payments, and hospitals can elect to be included in this,” says Cunningham. “What I am seeing in my consulting is that some hospitals are embracing this because it’s an opportunity to increase revenue. That surprises me.”

Cunningham says that for hospitals, the attractiveness to this development lies in the ability to increase revenue.

A New Landscape in Case Management

Bundled payments have “changed the landscape” of case management in recent years, says Toni Cesta, PhD, RN, FAAN, owner and consultant for Case Management Concepts, LLC, in North Bellmore, NY.

“RN case managers and social workers can no longer focus only on the inpatient setting but rather must incorporate across-the-continuum strategies into their daily workflow,” says Cesta.

She says that such changes include a greater emphasis on care coordination and transitions in care.

“In terms of care coordination, hospital-based case management professionals must complete comprehensive assessments and daily reassessments of the patient’s ongoing needs while hospitalized and after transition to the community.”

Cesta adds that care coordination is an essential role of the hospital case manager and that it has a direct impact on length of stay, cost of care, patient satisfaction, and patient outcomes.

“Each day of the hospital stay must be optimized in order to ensure third-party payer reimbursements and to reduce nonessential patient care days,” she says. “At the same time, the hospital case manager and social worker must keep an eye on the patient’s post-acute needs and provide written and oral information about the patient during all transitions in care.”

Creating linkages across the continuum between healthcare providers, patients, and families is a core responsibility of case managers and social workers, both in the community as well as in the acute-care setting.

By keeping the patient at the center of the process, case managers can ensure that his or her needs are met at all touchpoints across the continuum, rather than based on specific providers.

“There’s a nurse navigator who follows people telephonically for up to 90 days to make sure there are no gaps in care and to follow up with the patient and see if they have any questions or need further intervention,” says Cesta. “The other type would be a nurse navigator who is based in the community rather than the hospital and who has a longer-term relationship with the patient, following their care and monitoring their lab results or other diagnostic tests, physician appointments, or other care needs.”

It helps the patient to manage and navigate the complex healthcare system and to reduce ED visits or readmissions to the hospital.

“It gives them a name and a face that represents the healthcare system to them and someone they can go to if they have questions or concerns,” says Cesta. “It’s a win-win for the healthcare providers. Nurse navigators serve as an intermediary between the patient and the physician.”