2. Meeting Objectives
1. EDUCATION:
Ensure we have a common understanding of
bundled, episode-based payments.
Share BMCHP & ACAPs learnings from evaluating
bundles and potential bundle “candidates.”
2. FEEDBACK: Get your feedback on key
questions that drive BMCHP’s decision to move
forward with bundled payments.
3. Project Goal
Work with BMCHP team to recommend
action, or no action, on a bundled payment
program/pilot.
If action is recommended, determine next
steps on:
Bundles to pursue
Providers to consider
BMCHP implementation team
4. Timeline
June
• Meetings with Quality and
Finance teams gather
information/feedback.
• Learn more about
bundling: Interview
experienced provider and
MMCO.
July
• Gather key internal data.
• Draft recommendation.
• Incorporate feedback on
recommendation.
August-
September
• BMCHP
leadership
evaluates rec.
5. Education:
What is a bundled payment?
Bundled payment is a single payment to providers or
health care facilities (or jointly to both) for all services to
treat a given condition or provide a given treatment.
There are several approaches to defining a bundle but
all link payment for services provided to a patient with a
medical problem within a specific period of time by one
or more providers.
Bundles selected should be supported by strong
evidence based medicine and quality metrics.
Significant ambiguity around what represents a good
outcome is problematic.
6. Education:
Bundled payment rationale
Bundles are a form of value based provider
payment. Compared to straight fee-for-service,
value based payments tie reimbursement to what
providers achieve rather than what they do
(quality of care vs. volume).
CMS and other purchasers believe bundled
payments may lead to higher quality, more
coordinated care at a lower cost and are
encouraging demonstrations. BMCHP is
interested in piloting the concept.
7. Education:
Bundled payment example
Pregnancy and Delivery (ACAP recommendation)
Definition: Episode as live birth, bundle time period spans 40
weeks prior to delivery and 60 days post-delivery, bundle
includes all pregnancy related services (not neonate care),
and responsible provider is the provider or provider group
that performed the delivery.
Measurement: Budget based on historical cost of same
bundle of services for the participating provider, provider will
receive 50% of any savings over budget, provider must meet
quality threshold using the following measures: HIV
screening, Group B Strep screening, chlamydia screening,
and post partum follow-up.
9. Education:
Key questions/decisions on
the path to bundled payments
Our Discussion Focus
Which bundles?
What’s in the bundle?
Which providers would participate?
Which quality metrics would be used (by bundle)
to reward performance?
How to structure financial reward?
What kind of support would providers need? Can
BMCHP provide that support?
10. Feedback:
Which conditions?
Identify most prevalent conditions
Is there a sufficient volume to make the episode-
of-care viable?
Identify conditions that are most costly
Variability in costs
Consider potentially avoidable complications
(PACs) – are these driving costs up?
14. Feedback:
Which conditions?
Are ACAP’s recommendations the right bundles to
pursue?
Would you recommend alternates?
Would you take any conditions off the table (given
prevalence, cost and opportunity)?
What additional data do you have/or we need to make
this decision? Possible to collect?
15. Feedback:
What’s in the bundle?
Given your clinical condition recommendation, can
you recommend what should be in the bundle
(given clinical or finance hat)?
Budget, risk model, responsible provider, member
enrollment/exclusions
What additional data do you have/or we need to
make this decision? Possible to collect?
16. Feedback:
Which providers?
Do the conditions under consideration
crosswalk potential providers and the services
they provide?
Do we have enough providers to make it
work?
Do they have the capacity to participate?
How will we gauge interest in providers to
participate in bundled payment programs?
17. Which quality metrics will be used to evaluate
clinical outcomes?
Do metrics exist for suggested bundle?
Have they been used in other states?
Develop benchmarks - tests, screenings,
readmission rates, decreased PACs, etc.
How will quality metrics be used to determine
performance?
Compare to baseline, past performance, or
other providers?
Feedback:
Which quality metrics?
18. Is it possible to evaluate quality metrics used
in other state to learn if applicable to MA
providers?
What else needs to be done to get to
applicable quality metrics?
Feedback:
Which quality metrics?
19. Feedback:
Determine budget bundle
Identify historical costs of individual physician,
provider group, institution, geographic or
market place, etc.
Identify all expected services within an
episode and use payer rates to build the
budget.
Will the budget be risk-adjusted or will each
individual episode be a flat fee budget?
Will complications be adjusted for?
Will providers be given a margin?
20. Feedback:
Determine risk model
Vary by provider?
Vary by condition?
Shared Savings
Shared Risk
Discount Arrangement/guaranteed savings
Full Risk
