Designing a commercial bundle for cardiac procedures: The Percutaneous Coronary Intervention Episode Payment Model

Abstract

BackgroundCardiac interventions account for a significant share of overall healthcare spending and have been the focus of several large-scale interventions to develop effective bundled payments. To date, however, none have proven successful in commercially insured populations. In 2018, we worked with Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield of Hawaii, to design a novel commercial bundled payment for percutaneous coronary interventions, the Percutaneous Coronary Intervention Episode Payment Model (PCI EPM). MethodsDescriptive analysis of HMSA's PCI EPM, including its inclusion criteria, contents of the bundle, target prices, shared savings model, and incentivized quality metrics. We also compare HMSA's PCI EPM to Medicare's Bundled Payment for Care Improvement programs and the cancelled Cardiac Care Model. ResultsHMSA's PCI EPM was designed through an iterative process with cardiologists and is the first commercial bundle to specifically target a cardiac procedure. PCI EPM incorporates site neutrality and incentivizes providers to shift care to the outpatient setting when medically permissible. Compared to existing non-commercial models, PCI EPM incorporate first-dollar shared savings and incentivized fewer quality metrics. ConclusionsReviewing features of the Percutaneous Coronary Intervention Episode Payment Model in comparison to existing Medicare programs is intended to help guide health plan and health policymakers when designing programs and policies related to cardiac interventions. ImplicationsBundled commercial payments for interventional cardiology procedures are promising and should continue to be further explored. Level of evidenceVI.