Medicare Bundled-Payment Model Could Expand Access to Value-Based Specialty Care
By Emma Freer

Medicare’s recent extension of a bundled payment model marks a rare opportunity for more specialists to participate in value-based care and could pave the way for better coordination with primary care. 

The Centers for Medicare & Medicaid Services (CMS) announced it will continue testing the Bundled Payments for Care Improvement Advanced (BPCI-A) model through 2025 – two years beyond its original end date of Dec. 31, 2023 – as part of its broader strategy to shift patients from fee-for-service arrangements to value-based care relationships by 2030. 

BPCI-A is a voluntary advanced alternative payment model under Medicare’s Quality Payment Program that bundles payment for services provided during 90-day episodes of care. Participating hospitals and physician groups – comprising nearly 70,000 clinicians, mostly hospital-based specialists – are held accountable for the costs and outcomes of such episodes. 

Asim Usman, MD, an internist in Greenville and a member of the Texas Medical Association’s new Task Force on Alternative Payment Models, says his multispecialty medical group has participated in BPCI-A since its inception in 2018 and in its predecessor, BPCI Classic. 

“We knew at that time in 2015 that [bundled payments] would be the future, and we felt it was a great way to be ahead of everyone else,” he said. 

Since then, Dr. Usman says his medical group has improved patient outcomes while decreasing costs, earning incentive payments each year it has participated in the model.   

With this extension, CMS is testing whether BPCI-A encourages other clinicians to do what Dr. Usman’s group has done: “invest in practice innovation and care redesign to improve care coordination and reduce expenditures while maintaining or improving the quality of care for Medicare [patients],” according to a CMS fact sheet.  

BPCI-A also plays an important role in the CMS Innovation Center’s broader strategy to test alternative specialty care payments for Medicare and Medicaid services. The federal agency laid out a four-pronged approach to expanding access to high-quality, value-based specialty care in a Nov. 7 blog post: 

Improving transparency around specialist performance data and quality measures; 

Ramping up bundled-payment models, like BPCI-A; 

Improving coordination between primary care physicians and specialists; and 

Creating financial incentives for accountable care organizations (ACOs) to manage specialty care. 

Kim Harmon, TMA associate vice president of innovative practice models, is optimistic about this strategy and its potential to facilitate collaboration between primary care and specialty physicians. It builds on previous, single-specialty care models, such as those focused on orthopedics, oncology, and kidney disease. But she says success hinges on physician participation in model design and on such models being voluntary to encourage physician buy-in.  

CMS hopes to take the lessons learned from BPCI-A's extended run and develop a new, mandatory bundled payment model geared toward improving patient outcomes during hospital-based and post-acute care transitions. The agency’s blog post describes these episodes as “a common point in the care journey where lapses in quality occur and which are often beyond the reach of primary care-based ACOs.”   

Dr. Usman understands this challenge. He says his group is held accountable for the care patients receive in skilled nursing facilities but is unable to manage how those facilities operate.  

Helping other physicians navigate thorny issues like this is his top priority as a member of TMA’s Task Force on Alternative Payment Models, which will monitor the extension of BPCI Advanced as well as the CMS Innovation Center’s related initiatives.  

"One of my agendas is to spur greater investment in bundled programs and develop more support for our medical groups in Texas, so that any medical group who wants to participate can do so,” he said.  

CMS plans to open applications for BPCI Advanced early this year for 2024 and 2025. To be eligible, clinicians must be enrolled in Medicare or a Medicare ACO. Clinicians who already participate may remain in the model.