TASK 2 WK 3

Hello Motivators, 

Please see the attached task and write a 600-800 response with support references. Please do not re-write what the writer says or use their references, use your own original thoughts. You don’t have to respond to the entire post, just pick out a few highlights and comment on them with supportive references. The attached document can be used as a help aid for the kind of response that will satisfy this task.  Thanks in advance.

  Bundled Payments for Care Improvement (BPCI)

  1.       Background and description of the problem

Under a traditional fee-for-service (FFS) reimbursement model within healthcare, Medicare pays separately each of the distinct providers that render services to a patient during a particular patient-care episode. Under the Bundled Payments for Care Improvement (BPCI) model, payments from Medicare for a patient’s particular episode of care are linked together amongst the various providers, establishing a level of clinical and financial accountability and greater coordinated care between those very same providers. [1] For example, for a knee replacement administered under BPCI, the various providers included in the provision of care - the hospital for surgery, the surgeons themselves, the post-acute provider for rehabilitation, the pharmaceutical provider, etc. – would all be reimbursed collectively under one Bundled Payment amongst and between the various providers. Comparing the traditional fee for service model to BPCI has been described by some as being comparable to “paying for a meal ala carte versus a prix fixe menu”. [2]

Established under ACA in 2011 and first initiated in 2013, BPCI is administered through four broadly defined models of care, with the ultimate goal of providing this more coordinated care to result in higher quality and a lower cost to Medicare. The previous FFS model has been thought of providing fragmented care because of the minimal coordination of providers, with BPCI providing incentives for those providers to work closely together to create clinical and financial efficiencies.[3] Furthermore, proponents of BPCI underscore not only the efficiencies created when heretofore distinct providers are aligned under coordinated and dependent reimbursement, but also, more transparency for health care consumers, whether those consumers be employers, health insurers or the patients themselves.[4]

 2.  The Solution and its challenges

 Under BPCI, the various providers are generally required to reduce Medicare costs by 2-3.5% in order to avail themselves of the program financial incentives, the idea being that can budget resources of and cost services in a more efficient way, lowering costs to Medicare, Medicaid and Children’s Health Insurance Program (CHIP) and again, enhancing the quality of care to the Medicare beneficiaries themselves. [5] While forward thinking in terms of addressing the problem of both rising costs and access to quality care for patients, there are ongoing concerns about the risks to the various participating providers in BPCI, specifically with regard to:

· How the apportioned savings and financial incentives (also known as “gain sharing arrangements”) would be reached

· The specifics of the mechanisms for cost control within the particular bundle

· How to safeguard the individual provider’s ultimate control over treatment decisions in the face of cost-containment pressures.[6]

While some of the Bundles that are being phased will become mandatory for certain providers in certain markets over time, most are strictly voluntary at this point. Furthermore, while BPCI is changing the landscape as more and more providers do begin to make the leap from FFS models to BPCI, because of the issue of assumption of risk through the financial incentives, providers are still tempted to stay with the familiarity of FFS and avoid potentially risky BPCI initiatives.[7]

To achieve compromise within the initiative (and keep it so given that it is ongoing), there is constant negotiation between providers of varying types on coordination of episodic care. The sharing of transparent data is key to this, so different providers and provider types considering participating in a particular bundle are fully aware of the quality outcomes and cost effectiveness of partnering with other provider types. This has been and will continue to be a major assessment tool for providers to participate within BPCI initiatives and make a fuller leap from FFS to BPCI in order to avail themselves of the cost containing and quality seeking goals of BPCI.

3. The Stakeholders

Some of the various stakeholders – stakeholders who are not only included in getting this piece of ACA passed but also who are critical to its ONGOING success given the voluntary participatory nature of the program, include:

 

· Centers for Medicare and Medicaid Services – Charged with developing programs that enhance the three pillar of healthcare – Cost, Access and Quality

· American Hospital Association – Representing the interests of hospitals as key providers within BPCI and their interests and risks within the BPCI initiative

· American Health Care Association - Representing the interests of long term care providers as key providers within BPCI and their interests and risks within the BPCI initiative

· American Medical Association - Representing the interests of physicians as key providers within BPCI and their interests and risks within the BPCI initiative

· Health and Human Services Secretaries (former and current) - Kathleen Sebelius (who resigned as a result of the disastrous roll out ofObamacare) and Sylvia Mathews Burwell (current), who will be responsible for continuing the oversight and growth of BPCI as a policy initiative

· Other (non-governmental) Insurance Payers – As BPCI initiatives are successful for Medicare, these payers may be expected to structure their payment mechanisms around comparable components as BPCI.

· States as Administrators of Medicaid Programs - – As BPCI initiatives are successful for Medicare, individual states may be expected to structure their payment mechanisms around comparable components as BPCI for Medicaid in the future.

These various stakeholders each represent(ed) large constituencies that voice(d) opinion as BPCI is phased in and continues to accumulate more and more providers.

 

1. Policy Analysis and rationale for BPCI inclusion in final ACA

It really came as no surprise that PPACA, the most comprehensive healthcare legislation since the establishment of Medicare, would include new and innovative ways to reduce costs, increase quality and access to services via BPCI. From a “Window of Opportunity perspective”, all three streams for potential policy development were clearly present.

From a “problem perspective”, the need to lower costs was and is clearly present in all parts of the patient experience. All providers, employers, patients themselves, the various levels of government are aware of the need to lower costs but at the same time, keep up with the pace of developments in healthcaretechnology and advancement so as many people as possible have access to the quality of care that is available. The stakeholders – those charged with providing and representing clear public opinion on the need for change were loud in underscoring the political stream that not only called for ongoing change, but provided the power mechanism to develop and advance the cause of innovative approaches to cost, quality and access the way that BPCI did. Finally, given the national debate, the political support and the multiple agendas on exactly how to create alternative solutions to this issue/opportunity, it is again, not surprising at all that a large window of opportunity existed for policy advancement given the convergence of streams available. And while as recently as last year (June 2015) BPCI initiatives included over 7,000 hospitals, physicians and post-acute providers with the effects of experiment still remaining to be assessed [8], the policy environment has and will keep the window of opportunity for refinement and further development given the strong public, political and policy streams that exist surrounding this issue. It is then again, no wonder that it was an important piece of legislation within ACA, but one that will almost certainly continue to grow and grow, radically changing the healthcare delivery and reimbursement model as it continues to do so.

[1] Centers for Medicare & Medicaid Services (CMS), “Bundled Payments for Care Improvement Initiative (BPCI)”, CMS.GOV, April 18, 2016, retrieved fromhttps://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-18.html

[2] Klein, Eric & Mitchel, Lynsey, “Bundled Payments under the Affordable Care Act Continue to Gain Influence”, Healthcare Law Blog, August 8, 2014, retrieved fromhttp://www.sheppardhealthlaw.com/2014/08/articles/affordable-care-act-aca/bundled-payments-under-the-affordable-care-act-continue-to-gain-influence/

[3] Centers for Medicare & Medicaid Services (CMS), “Bundled Payments for Care Improvement Initiative (BPCI)”, CMS.GOV, April 18, 2016, retrieved fromhttps://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-18.html

[4] Klein, Eric & Mitchel, Lynsey, “Bundled Payments under the Affordable Care Act Continue to Gain Influence”, Healthcare Law Blog, August 8, 2014, retrieved fromhttp://www.sheppardhealthlaw.com/2014/08/articles/affordable-care-act-aca/bundled-payments-under-the-affordable-care-act-continue-to-gain-influence/

[5] Centers for Medicare & Medicaid Services (CMS), “Bundled Payments for Care Improvement Initiative (BPCI)”, CMS.GOV, April 18, 2016, retrieved fromhttps://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-04-18.html

[6] Fromison, Mark,& Rana, Adam, & White, Richard, & Marshall, Amanda, & Schutzer, & Steve, Healy, & William, Healy, & Naas, Peggy, &Daubert, Gail, & Iorio, Richard, & Parsley, Brian, “Bundled Payments for Care Improvement Initiative: The Next Evolution of Payment Formulations”,  AAHKS Bundled Payment Task Force   – The Journal of Arthroplasty, July 2, 2013, retrieved fromhttp://www.aahks.org/wp-content/uploads/2014/02/joa-bundled-payments-care-improvement.pdf

[7] Hackbarth, Glenn, “A Payment Reform Conundrum: Reconciling Conflicting Policy Goals”, Health Affairs Blog, January 27, 2016, retrieved from http://healthaffairs.org/blog/2016/01/27/a-payment-reform-conundrum-reconciling-conflicting-policy-goals/

[8] Blumenthal, David, & Abrams, Melinda, & Nuzum, Rachel “The Affordable Care Act at 5 Years”, The New England Journal of Medicine, June 18, 2015, retrieved fromhttp://www.nejm.org/doi/full/10.1056/NEJMhpr1503614?af=R&rss=currentIssue&#t=article