Preparing for the Inevitable: Mandatory Bundles in Musculoskeletal Care


Whether you currently participate in Centers for Medicare and Medicaid Services (CMS) orthopedic bundled payments, now is the time to better understand bundles and how to thrive with them. Several indicators suggest mandatory bundled payments are on the horizon for musculoskeletal care. Health systems and providers will be well served by adopting the foundations needed for success when these value-based care models become mandatory.

“The current head of CMS has signaled broader and more comprehensive mandatory bundled payments are coming, probably in the next two or three years as BCPI-A sunsets,” said DeLyle Manwaring, Executive Vice President of Market Transformation at Phoenix-based Healthcare Outcomes Performance Company (HOPCo). “In 2021, we are already seeing changes in the voluntary bundled payment system as the Center for Medicare and Medicaid Innovation (CMMI) launched radical changes, most notably changing bundles to all-encompassing clinical episode service groupings, which requires participants to take risk on a broad swath of DRGs, most notably, traumas.”

To learn more about these changes, read the following article.  Gone are the days when you can take risk only on the easy elective cases.

Another indicator of changes to value-based care models can be found in the incoming Biden administration. President Biden will likely want to bolster the Affordable Care Act, which originally called for mandatory bundles that were later rescinded by the Trump Administration. They are now more likely to happen as the administration looks for opportunities to strengthen the healthcare act for which Biden was an original author.

“At HOPCo, we believe these upcoming changes will continue to improve overall quality of care and reduce the total cost of each episode of care,” said Manwaring. “They also emphasize the need for orthopedic providers and health systems to begin preparing now for the future inevitability of mandatory bundled care programs.”

Medical practices and health systems can start preparing now by developing a platform for success, not only for mandatory CMS bundles but for commercial bundles as well.  The systems and capabilities needed for success with bundled payments include a robust data analytics engine, evidence-based clinical pathways and protocols, partnerships across the care continuum and teams experienced in managing every step in the process.

Imagine flying a plane through a storm without instruments. That’s what it’s like when you are taking risk on bundles without the right data analytics engine. Data and feedback from payors (commercial or government) can often be incomplete or misleading despite appropriate intentions. With the right data platform, developed by individuals and actuaries with decades of experience in payor risk and orthopedic bundles, the best and most timely information on performance will make the difference between guesswork and precision. This allows surgeons and hospitals to make real-time adjustments in clinical and operational practice to optimize care. By having the right instrument panel for outcomes, claims and results combined with timely data, hospitals and physicians can enhance opportunities for success and ensure both government and commercial payors pay appropriately and get the analytics right.

Evidence-based clinical pathways and protocols are crucial to identifying the best site for service and optimizing length of stay and recovery care. The appropriate pathways not only reduce variation and improve outcomes, they also give providers peace of mind that they are doing the very best for patients while managing risk. Surgeons and hospitals with strong value-based programs and teams experienced in managing every aspect of orthopedic bundles will be best equipped for success under mandatory bundle payment systems.

“HOPCo’s experience managing bundled payment models and value-based programs coupled with our suite of clinical decision support tools position our affiliated practices, hospital partners and payor networks for success with the future CMS mandatory models,” concluded Manwaring. “Our experts know the right questions to ask, where patients should be in each step of their treatment and recovery, and how to work with every provider across the continuum. We can optimize workflow, develop preferred networks, analyze data and equip surgeons and health systems for success in an environment of orthopedic bundles.”