CMS Missing the Mark on Bundled Payments, Experts Say

Marcia Frellick

April 10, 2018

Quality measures for bundled healthcare payments do not measure what patients value most and fail to encourage more appropriate care, say authors of a new article published online April 9 in the Annals of Internal Medicine.

Peter J. Pronovost, MD, PhD, from UnitedHealthcare in Minnetonka, Minnesota, and colleagues outline what they say needs to change with evaluating these payments that set a fixed amount for the total cost of care in a defined period surrounding a procedure.

At this time, measures for bundled payments look at cost, use of care, and short-term complications, such as 30-day readmissions, the authors explain. What the measures do not consider are whether a particular treatment or procedure is the most appropriate option or whether it will improve the patient's long-term health.

They also do not take into account diagnostic accuracy, the authors say, adding that it is now possible to measure diagnostic harm with better understanding of how to use large administrative data sets.

Most payment systems measure health status by the number of in-hospital complications. The Centers for Medicare & Medicaid Services (CMS) limits quality measurement for bundled payments to 90 days after a procedure.

But what is really important to patients is whether they can reach personal goals, the authors say. In the case of a sinus infection, that might mean fewer missed days of work.

Framework Should Ask Three Questions

The authors propose a measurement framework that answers three questions: "First, was the treatment appropriate? Second, did the patient's health improve? Finally, what did the treatment cost?"

They apply that structure to the CMS comprehensive care bundle for total knee replacement as an example. The authors would add appropriateness of joint replacement criteria to determine whether the surgery is necessary. Measurement of disability could be gleaned from the change in score from baseline to 1 year, using the knee injury and osteoarthritis outcome score. Costs could be determined by adding patient-reported out-of-pocket spending and time off work to the Medicare costs.

The authors say it is important to measure value as health benefit per dollar spent, and they add that it is important to consider who is paying what. Patients pay direct costs and indirect costs, such as time off work. Providers also incur costs when patients do not pay their bills.

Better measures are important, as bundled payments, part of the Merit-based Incentive Payment System, are becoming more common. The authors note that in 2016, about 29% of all reimbursements in the United States, including commercial payers' reimbursements, used alternative payment structures, including bundled payments.

The authors acknowledge that the framework they are proposing will require more efficient data collection and advancement in the science of measurements.

"[W]e think that the investments necessary to develop and implement these 'measures that matter' will be worthwhile because they will drive high-value innovations in diagnosis and therapy," they conclude.

One coauthor reports grants from the National Institutes of Health and the Agency for Healthcare Research and Quality during the study; grants from the National Institutes of Health, the Agency for Healthcare Research and Quality, the Society to Improve Diagnosis in Medicine, and other foundations; nonfinancial support from GN Otometrics and Interacoustics; and personal fees from law firms and multiple academic institutions outside the submitted work; and a diagnostic error career focus (academic conflict of interest). Another coauthor reports grants from the Patient-Centered Outcomes Research Institute, the Agency for Healthcare Research and Quality, CMS, the Greenwall Foundation, and AIG; and personal fees from GSK, ViiV, and Gilead outside the submitted work.

Ann Intern Med. Published online April 9, 2018. Abstract

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