Addressing the possible effects of overlapping reimbursement models

LH_low-resAt the core of bundled payments is the goal of improving coordination between all of the facilities and agencies a patient might visit or employ during one episode of care.

But as health care providers adjust to this new reimbursement model, some are experiencing trouble coordinating bundled payments with other value-based care initiatives.

In the latest #5in5 episode from Optum Provider Jeremiah Reuter, managing director, Optum Network in Population Health Consulting, explains how two shared savings models — the Bundled Payment for Care Improvement model (BPCI) and the Medicare ACO programs — can overlap.

He says a Medicare beneficiary might be aligned with a Medicare ACO and trigger an episode within the BPCI program if admitted for certain types of care.

“While the BPCI participants have performed a procedure, what Medicare pays for that procedure may penalize an ACO to which that beneficiary is aligned,” says Reuter. “The reason behind this is that CMS does not award savings twice. So when you have two programs that are generating savings for the beneficiary, we have to decide who receives credit for those savings.”

“It all depends on the target price set by Medicare for the bundled payment program,” says Reuter. “If the BPCI’s target price is higher than the ACO’s, and the BPCI performs the procedure, that’s where trouble arises.”

Bottom line: The concern is that without developing a way to reconcile reimbursements, the programs could end up rewarding less efficient providers and penalizing more efficient providers.

In the #5in5 podcast, Reuter answers five questions in five minutes on the importance of understanding the potential for an overlap. He explains why the issue is not limited to these CMS programs. And, he talks about proposals for prioritizing payments.

Click here to listen. 

About the Author:

Leslie Cozatt currently serves as Director of Marketing, Optum Provider – Thought Leadership and Content Strategy.

She directs the development of content that spotlights the role of data analytics in healthcare – specifically the transition to value-based care, risk management and population health management. She brings to her role more than 20 years of experience developing B2B and B2C integrated marketing campaigns for companies including ThreeWire, Eliance and 3M. Leslie attended the University of Minnesota and graduated from Wellington College with a BS in International Business & Communication.

Leave a Reply