Bundled payment success varies by condition
By tightening adherence to the clinical pathways, St. Joseph has been able to deliver better emergency department and inpatient care in the first six hours after sepsis is diagnosed.
St. Joseph Health System
in South Bend, Ind., can testify to how tough it is to succeed in the Medicare bundle for congestive heart-failure patients, even as it has done well with a different, challenging medical management bundle.
Dr. Stephen Anderson, St. Joseph’s chief medical officer, said the organization has had quarters when it met its CHF cost target and others when it did not, reflecting the high cost variability among heart-failure patients.
That’s common even among academic medical centers participating in the CHF bundle, with some patients running up costs of nearly $200,000 per episode when the cost target is $18,000, according to Jonathan Pearce, principal with Singletrack Analytics.
In contrast, St. Joseph has consistently earned Medicare savings payments on its bundled-payment program for sepsis patients since it started that program in late 2015. Anderson said one key difference between the two bundles is that his system hired a nurse coordinator, Rena Snell, for the sepsis program but is only now hiring one for the heart-failure effort.
Another factor is that before launching the sepsis bundle, St. Joseph already had a strong sepsis program, developed with the help of Trinity Health, its parent system. Trinity had encouraged its hospitals to adopt its evidence-based clinical pathways for sepsis treatment, including a standard order set embedded in the electronic health record system that comes up with a single mouse click.
By tightening adherence to the clinical pathways, St. Joseph has been able to deliver better emergency department and inpatient care in the first six hours after sepsis is diagnosed. That has made it more possible to send patients directly home rather than to a skilled-nursing facility for a week or two, sharply cutting costs and helping the hospital meet the bundled-payment target.
Still, Anderson noted there are other differences inherent to the heart-failure condition that make it a more challenging bundle than sepsis, notably that CHF patients, unlike most sepsis patients, have a chronic underlying disease. That significantly increases the likelihood of readmissions and SNF stays. Another big difference is that the key treatment time in sepsis is three to six hours in the ED, whereas heart failure treatment is spread out over multiple days and locations.
“We needed to be better prepared to manage the next transition with CHF patients than we had to be with sepsis,” Anderson said, explaining his hospital’s lack of success so far with the heart-failure bundle. He thinks St. Joseph can do better, and that it probably will participate
in the CHF bundle in the Bundled Payment for Care Improvement Advanced program.
Despite the challenges of working with the CHF bundle, providers overall are achieving savings on that and other medical management bundles, said Chris Garcia, CEO of Remedy Partners, which works with about 700 providers participating in the BPCI program.
Over the past eight quarters, providers working with Remedy have achieved 7.4% savings for medical management bundles and 7.6% for surgical bundles, on total program spending of about $6 billion for medical episodes and $2.5 billion for surgical episodes, according to Garcia. Savings on the CHF bundle have been lower, at about 5%.
Garcia thinks the lower savings rate for heart failure may be because hospitals already had reduced CHF readmissions as a result of the CMS readmission penalty for those patients. So there was less cost-saving opportunity in the CHF bundle. Still, he believes there is plenty of room to cut costs for heart-failure patients, as in other bundled clinical areas, by shrinking unnecessary post-acute SNF and rehab stays.
Pearce is less confident about the financial viability of bundles for heart failure and other complex medical management episodes— especially compared with surgical episodes like joint replacement—due to the much greater cost variability of the medical cases. “We’re telling hospitals, ‘Your cardiologists can’t do the same thing the orthopedists did,’ ” he said.