Commercial payers taking the plunge into bundled payment models? Some guidelines to help

Medicine Money
A new report offers keys to success for commercial insurers looking to offer bundled payments.  (Getty/utah778)

Bundled payment models could have a significant payoff for private payers, but only if it's done well.

A new report released by the Health Care Transformation Task Force—an organization that includes a variety of healthcare stakeholders including providers, payers, purchasers and patient advocates—offers several keys to success for those looking to take the value-based care plunge. The group issued guidance this week that identifies several steps commercial insurers should follow to launch a successful episodic payment program. 

These models have gained a foothold in Medicare, but uptake in the private sector has been slow. Jeff Micklos, executive director of the task force, told FierceHealthcare that is beginning to change. 

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“Payers have not necessarily embraced the clinical episode models, but we’ve seen that shift over the last 18 months to two years, as they find ways to adjust their systems in a way to more effectively administer” these models, Micklos said. 

RELATED: Geisinger, Dignity Health among 1,300 providers to sign up for CMS’ bundled payment model 

Private payers, he said, are studying new ways to apply bundled payments outside of the procedures Medicare covers in these models—maternity care being a prominent example.  

The patient population for commercial insurers is different than Medicare, so adapting the approach it uses for joint replacements or oncology to service lines that younger patients need is crucial. 

“A maternity model is of the greatest interest and most in demand,” he said. 

The first key to success, according to the task force, is engaging more effectively with providers—especially specialists. Micklos said that building stronger lines of communication with specialty care is one of the most attractive pieces of bundled payment models, as that is often one of the costliest areas of care. 

Providers have also already invested significantly in the infrastructure needed to administer bundles in Medicare, so their guidance could be beneficial in setting up a similar payment structure at a private insurer, he said. Better communication with providers can also ensure that the second key is addressed: Bundled payment contracts must be structured in a way that puts the clinicians in charge of patients, with clear incentives for coordination and cost reduction. 

RELATED: HHS sets 3 priorities for new physician-focused payment models 

Providers also need to have access to a payer’s treasure trove of use and cost data to map variability and follow the money, according to the report. Transparent data sharing is the backbone to success in most developing alternative payment models. 

Alongside the guidelines on building bundled payment contracts, the task force issued a report to help commercial payers identify or build the right episode grouper, a software program that lumps claims data into episodes of care. 

These programs are very customizable, according to the report, and because technology changes rapidly there are several lenses to use to evaluate the best fit. This means the programs must be built to account for the differences within a patient population and how to most fairly attribute costs. 

“The use of episode groupers to better understand healthcare costs, in concert with the limited transparency and inherent complexity of their methodologies, has created the need for an evaluation framework,” according to the report.