Despite the Trump administration’s preference for voluntary programs, a new study found mandatory CMS bundled payment initiatives are more effective.
Mandatory bundled payment programs “generate robust evidence and either mandatory or additional targeted voluntary programs may be required to engage more hospitals in bundled payments,” according to the study in Health Affairs.
The report said hospitals that take part in voluntary programs spend slightly more on institutional post-acute care at baseline.
Bundled payment models are among the more popular forms of value-based reimbursement, but there has always been a thorny question in whether some providers should be forced to participate.
A mandatory program ensures enough physicians are involved to really move the needle on cost cutting and care improvement, and is more likely to generate adequate data to determine a program's effectiveness. Providers, however, balk at being told they have to take part in a model that can have a significant administrative burden for which they may not be adequately prepared.
The study authors analyzed data from Medicare and the American Hospital Association Annual Survey. They compared characteristics and baseline performance for hospitals in Medicare’s voluntary and mandatory joint replacement bundled payment programs. Bundled Payments for Care Improvement (BPCI) is voluntary, while Comprehensive Care for Joint Replacement (CJR) is mandatory.
The report found organizational differences between the hospitals in each program, which shows BPCI and CJR “engaged different types of hospitals.” The study authors warned the results from BPCI “might not be as generalizable as those from CJR.”
The researchers found BPCI hospitals had higher mean patient volume. The facilities in the voluntary program were also larger and more teaching-intensive than those in the mandatory CJR program. The two groups had similar risk exposure and baseline episode quality and cost, but BPCI hospitals had a higher cost connected to institutional post-acute care. That was driven mostly by inpatient rehabilitation facility cost, the report said.
The Trump administration supports voluntary programs, moving away from Obama-era mandatory demonstrations. CMS Administrator Seema Verma has called mandatory programs too restrictive.
However, critics charge that voluntary programs don’t offer a complete look at the payment model. The authors of a recent report from JAMA said BPCI's voluntary aspect is a weakness. There has also been little interest from hospitals. Only 12% of eligible hospitals signed up for BPCI. Almost half of them dropped out for at least one condition.
The healthcare indsutry is closely watching the voluntary programs, including the new Bundled Payment for Care Improvement Advanced (BPCI-A) payment model. The first set of BPCI-A participants will begin the program Oct. 1. The results for value-based reimbursement attempts have been mixed so far regarding reducing costs and improving health outcomes, but bundled models in particular will continue to be tweaked and evaluated as the value movement continues.