Bundled Payment Lessons Remain Valuable for Home Health, Skilled Nursing Providers

Despite high hopes when it was introduced in 2012, the Bundled Payment for Care Improvement (BPCI) program has become somewhat of an afterthought for the home health industry.

Diminished excitement surrounding bundled payments is partially because post-acute providers, including home health and skilled nursing agencies, can no longer be episode initiators under the upcoming BPCI Advanced model. As a result, hospital providers and physician networks—not home health interests—will likely take the lead in development going forward.

But there’s still ample opportunity to leverage valuable insights from the lessons learned thus far, according to industry excerpts participating in a panel discussion at the Post Acute 360 conference in National Harbor, Maryland, on Monday.


Under BPCI, the Centers for Medicare & Medicaid Services (CMS) provides a single lump sum reimbursement for all the providers along the continuum that take care of a patient in a single episode of care, with the exact amount based on how much the agency determines specific health care events, or episodes, should cost in total.

Physician groups and hospitals will need solid home health and skilled nursing referral partners to succeed under new models, experts say. When home health agencies and skilled nursing facilities take the lead in patient care, that’s where past BPCI lessons learned could come into play.

Denise Burgen, formerly the chief quality and innovation officer for University of Rochester Medicine Home Care, said that the increased emphasis on data under BPCI helped her organization identify the best potential SNF partners for her company moving forward.


“We were able to figure out which of the skilled nursing facilities and rehabs had better outcomes in terms of readmissions, and were able to kind of select the preferred providers that we would send those patients to when they went into the episode,” Burgen, also a professor of clinical nursing at the University of Rochester, said during the event.

Plus, as the population ages and acute providers’ reimbursements are increasingly tied to how well patients perform as they travel through the care continuum, post-acute providers will naturally grow in importance to gain a certain level of equal footing.

“We are using the lessons we learned from BPCI when working with other payers,” Mary Moscato, president of the Boston-based Hebrew SeniorLife Health Care Services, said. “Hospitals will not be the center of everything in the future. We will be.”

Bundled payment models, such as the Comprehensive Care for Joint Replacement (CJR) model, have largely been seen as opportunities for home health, which can help keep costs down for episodes of care while driving quality outcomes. CMS reduced the number of mandatory geographic areas participating in the CJR model from 67 areas to 34 in late 2017.

About 465 Inpatient Prospective Payment System (IPPS) hospitals in 67 different Medicare Set-Aside Arrangements (MSAs) were reportedly participating in the CJR model as of Feb. 1, 2018.

Other bundled payment insights 

Similar to home health operators, SNF operators have invested significant resources in the BPCI program since it was first introduced. That investment won’t go for naught because successes and failures still matter, especially when it comes to coordination with payers.

“We are using the lessons we learned from BPCI when working with other payers,” Moscato said.

Those payers, including the state of Massachusetts’s Medicaid program in Hebrew SeniorLife Health Care Services’ case, increasingly want to hear about reduced costs, lower lengths of stay and other key metrics providers were able to glean from their participation in BPCI, she said.

Hebrew SeniorLife, which offers a continuum of care options from skilled nursing to home- and community-based services, saw readmissions drop from 15% down to 6% in the most recent month for which data was available, in part due to its participation in BPCI. It also notched net patient reconciliation savings of $2 million.

“And that, for a skilled facility today—anyone will take that,” Moscato said.

Health care providers and networks have not always had such financial success with BPCI, however. Susan Adams—vice president of alliance integration at the Masonicare network of acute, post-acute, and rehab facilities in Connecticut—said BPCI’s effects on her company’s bottom line were hit or miss.

“We have very positive quarters, and we had not-so-positive quarters,” Adams said.

Financial results may have been uneven, but the overall BPCI experience has been nonetheless beneficial, according to Adams.

Lessons from its participation helped Masonicare provide better care coordination, for example. Toward the beginning of its participation, the network’s SNFs weren’t even referring residents to its own home health agencies, something Masonicare was able to eventually improve upon, Adams said. Additionally, Masonicare learned not to bite off more than a single network can chew: The company initially signed on to participate in 25 bundles, which was eventually adjusted down to 13 and then finally seven.

“Trying to do all things well isn’t something that we achieved, but I think knowing that we were doing something right was helpful,” Adams said.

The Post Acute 360 conference, which ends on Wednesday, is organized by Lincoln Health Leadership. The goal of the conference is to help large post-acute providers understand the emerging post-acute ecosystem and implement the right solutions to enhance their value within it.

Written by Alex Spanko