Carolina, a private practice, from their early experience with
BPCI for spine surgery at the 2017 Annual Meeting of the
American Academy of Orthopedic Surgeons. OrthoCarolina
created clinical guidelines, analyzed the financials and outcomes, developed data collection systems and a bundled
payment management team led by the senior author, Dr. Leo
Spector, a spine surgeon and the Chief Quality Officer. In spite
of this infrastructure, the practice was not able to decrease the
costs and improve the outcomes for spine surgery. Because
the practice was successful in the other subspecialties, the
authors believe defining spine bundles by DRG is not ideal.
OrthoCarolina thought there was too much variability in the
types of surgical procedures included in the DRGs. Furthermore, the volume of spine surgery is too low to overcome that
Commercial bundles present an opportunity to align incentives and benefit all stakeholders especially in competitive
markets. For payers, commercial bundles have significant savings potential across episodes of care. Providers may benefit
from drawing in new patient volume, and new revenue from
coordinated care savings. Patients may feel more reassured
with participating in systems of highly coordinated care.
Commercial bundles across the United States, however,
demonstrate significant heterogeneity in payer, provider,
procedure, components and financial risk agreements. Payer
arrangements vary from simple models within one’s own organization, health plan or accountable care organization to
more complex arrangements with multiple local and national
payers. Provider participation also varies dramatically, from
only surgeons to multidisciplinary arrangements with all
associated specialties and organizations providing pre– and
postacute care (ie, rehabilitation and skilled nursing facilities).
The procedures and patients included within the bundle may
also vary dramatically to a single-level procedure like anterior
cervical discectomy and fusion (ACDF) on a narrow range of
healthy patients, to more inclusive bundles treating the full
gamut of cervical, thoracolumbar spinal conditions. Similar
to the four BPCI models, the components in the bundle range
from surgeon and hospital fees to perioperative care packages
extending 90 days. Unlike government-designed bundles,
commercial bundles can be designed with flexibility. For
example, the bundles could be defined by CPT code rather
than DRG. Creating bundles by CP T code may provide a more
homogenous patient pool.
Limitations of Bundles
For institutions exploring whether bundled payment arrangements make sense, the benefits must outweigh the disadvantages and any barriers must be surmountable.
Several barriers have limited more widespread adoption. 12
These may include: a relatively low volume of spine procedures meeting bundle inclusion criteria that does not justify
the cost of establishing the supportive infrastructure needed;
heterogeneity of spinal pathology and treatment; difficulties in
obtaining and processing data to predict reimbursement rates;
inflexible billing/reimbursement structures; and difficulties
coordinating postdischarge care.
Recommendations for Interested Institutions
Before participating in any type of bundled payment initiative,
it is important for institutions to analyze clinical and financial
practice trends to identify areas and solutions of improvement in the value equation. It is also critical to develop the
infrastructure to develop, implement and manage the program. Some key components of infrastructure include data
mechanisms/data analysts and patient navigators. Financial
data and outcome data need to be collected, tracked and
analyzed continuously so that improvements can be made
relatively quickly to ensure success. Case managers, or patient
navigators, are important to guide patients through the system and reduce expensive and unnecessary consumption of
health care services. Another key to success is to incentivize all
providers to participate in the institutions’ bundles. Engaging
providers in the design, implementation and management is
critical. Full provider participation increases the patient pool
and overcomes variations with increased volume.
Alternative Payment Models According to MACRA
While bundled payments are considered an alternative type
of payment model, a bundled payment arrangement may not
meet the criteria of an APM as defined by CMS in MACRA.
Entry into a bundled payment alone does not necessarily
guarantee that one will qualify for fee schedule bonuses under
MACRA thresholds. Given the important implications for
spine providers, further discussion of Alternative Payment
Models (APMs) is warranted.
APMs are new approaches to pay for medical care through
incentivizing quality and value. At their core, APMs are payment models under which clinicians undertake double-sided risk
for providing coordinated care.
MACRA does not change how
APMs function or reward value,
but instead creates extra incentives
for APM participation. Bundled
payment models are the most
prevalent APMs. The BPCI, as discussed above, is a CMS program that began to pilot bundled
payments for select diagnosis-related episodes of care. The
Comprehensive Care for Joint Replacement (CJR) model is
the well-known CMS bundled pilot program currently under-way—more on these APMs to follow. Ultimately, MACRA has
defined APMs as CMS Innovation Center Models (ie, BPCI),
Medicare Shared Savings Program, and various CMS demonstration projects. Alternative models of payment have clearly
existed before MACRA, but the new legislation defines how
APMs can qualify for incentivized payments.
Cho CH, Rosolowski
K, Waxler A, Hayden P.
MACRA Final Rule: New
SpineLine. 2017; 18( 1): 35-41.