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Overlapping payment models: Who gets paid?

September 10, 2019

Topics: Quote of the Day

By Tara Bannow
Modern Healthcare, September 7, 2019

The problem of overlap in the CMS’ various payment initiatives, including ACOs and bundled-payment programs, can introduce confusion and frustration when it comes to determining which program gets credit for those patients’ care. The CMS wants to avoid double-rewarding for savings on an individual patient’s care, such as if the patient is in an ACO and received qualifying care from a Bundled Payments for Care Improvement Advanced provider. So when it comes down to reconciling who is credited for the savings, things get tricky. And they’re bound to get even more complicated as the CMS adds alternative payment models to the mix.

New research highlights just how sweeping the problem is. More than 1 in every 4 patients receiving care under the CMS’ flagship bundled-payments program, the Bundled Payments for Care Improvement initiative, were also attributed to its flagship ACO program, the Medicare Shared Savings Program, in 2016, according to an August study in the Journal of Hospital Medicine. Conversely, 1 in every 10 MSSP patients received care at a BPCI participating hospital in 2016.

The CMS attempted to clarify things in June when it announced that starting in 2020, providers participating in BPCI Advanced will take precedence over all MSSP beneficiaries—meaning, their savings will be carved out from the ACO’s savings. Currently, this is only the case for certain MSSP beneficiaries, those categorized under the program’s basic track.

On a practical level, the June announcement means if John Doe is a patient in an MSSP ACO, and is admitted to a BPCI Advanced hospital with a clinical episode, such as congestive heart failure, that episode of care will be attributed to the BPCI Advanced provider, said Gina Bruno, vice president of value-based care with naviHealth.

The CMS is also trying to calculate a way to compensate aligned ACOs for their contributions to those patients’ care, Bruno said. “ACOs, especially those that work with BPCI Advanced providers will say, ‘Well, wait a minute. John Doe has been our patient for a period of time. We have a team that follows up with him. We play a part in managing his chronic disease. How do we get credit for our contributions to his outcomes?’ ”

Therein lies the trickiness of overlap. Experts say providers who contributed to a patient’s care often wind up feeling as though they didn’t get the commensurate reward.

“There is a risk of expending resources to support patients who ultimately are not attributed to the model to which that operating expense was aligned,” Bruno said.

At least five CMS payment models could overlap with one another: MSSP, BPCI Advanced, CJR, the advanced primary-care medical home model Comprehensive Primary Care Plus and the Oncology Care Model, said David Muhlestein, chief research officer with Leavitt Partners.

“If everybody is getting credit for it, you could potentially pay the same bonus payment five times,” he said. “Or if everybody does really poorly, all of them would pay the same penalty payment.”

There’s also a broader societal problem with overlap. It makes it difficult for the CMS Innovation Center to study whether its payment model experiments are actually saving money and improving patient outcomes. In that respect, the CMS is between a rock and a hard place, Muhlestein said.

“If they want to test many different programs to find out what works currently and not have overlap, you kind of can’t,” he said.



By Don McCanne, M.D.

While the policy community is ignoring the truly effective model of Single Payer Medicare for All, they remain fixated on accountable care organizations (ACOs) and alternative payment models (APMs). Not only has the initial experience with these models been relatively disappointing, the patients may be simultaneously enrolled in multiple models, often without their knowledge, creating confusion as to which entity should be receiving payment or assessed a penalty for falling short on parameters of care.

As David Muhlestein of Leavitt Partners states, “If they (CMS) want to test many different programs to find out what works currently and not have overlap, you kind of can’t.”

Yesterday’s Quote of the Day made the point that we don’t need more policy studies to figure out how we can fix the system. We merely need to enact and implement the single payer model of an improved Medicare for all.


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About the Commentator, Don McCanne

Don McCanne is a retired family practitioner who dedicated the 2nd phase of his career to speaking and writing extensively on single payer and related issues. He served as Physicians for a National Health Program president in 2002 and 2003, then as Senior Health Policy Fellow. For two decades, Don wrote "Quote of the Day", a daily health policy update which inspired HJM.

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