Reshape Your ACO Using Shadow Bundles

Key takeaways:

• A key element of the Centers for Medicare and Medicaid Services' specialist provider engagement strategy involves enhancing the types of data and performance metrics available to ACOs.
• Shadow bundles serve as a benchmark for payment calculations within an Accountable Care Organization and can provide a different lens from which to evaluate and engage specialists.
• Premier offers a wide range of expertise in bundled payment model readiness, preparation, development and implementation.

Sixty percent of all medical office visits are attributed to specialist care, accounting for 63 percent of all U.S. healthcare expenditures. Between 2000 and 2019, Medicare beneficiaries seeing five or more physicians increased from 18 percent to 30 percent, and the mean number of annual specialist visits increased by 20 percent.

Alongside this increased utilization, the Centers for Medicare and Medicaid Services (CMS) recently began releasing episodic-level data (or “shadow bundle” data) to its Medicare Accountable Care Organizations (ACOs) to provide greater insight into specialty care furnished to ACO beneficiaries.

This move is part of CMS’ overarching strategy of improving specialist engagement in value-based care models, as CMS looks ahead to its ambitious goal of moving all traditional Medicare beneficiaries into an accountable care relationship by 2030. 

A primary element of CMS’ specialist engagement strategy involves enhancing the types of data and performance metrics available to ACOs to better incentivize integration of specialists – aiming to improve access and coordination of primary and specialty care to meet the needs of patients.  Until now, ACOs and bundled payment programs have been developed on parallel, yet separate paths.

So, what are shadow bundles and how could they strengthen your ACO?

Breaking Down Shadow Bundles

A recent CMS survey found that 95 percent of ACO respondents indicated they were likely or very likely to utilize shadow bundle data to support better specialty engagement. 

Shadow bundles are alternative reimbursement arrangements that serve as a benchmark for payment calculations within an ACO. They provide a reference point for evaluating the cost and quality of care provided by the participating healthcare providers.

A shadow bundle uses Medicare claims data for items and services constructed into discrete procedural or condition-specific episodes of care. Episodes are constructed based on a consistent set of rules for ACO-attributed beneficiaries who meet the criteria to trigger an episode.  

While ACOs already receive claims data for their beneficiaries, configuring claims as clinical episodes with related target prices provides a different lens from which to evaluate specialist performance.

The Role of Shadow Bundles in Strengthening ACOs

It’s clear that actionable data, performance metrics and greater transparency can enhance access to high-quality, accountable care – and the use of shadow bundle data in ACOs can bring numerous benefits:

1. Provides a Deeper View of Specialist Performance: Shadow bundle data can facilitate transparency, comparability of performance and help identify areas of opportunity for improvement, including variations in practice patterns, utilization of services and care quality. Access to this data promotes healthy collaboration and can serve as an entry point to creating consistent communication and deeper engagement with specialist providers. Using unblinded, transparent data can incentivize peer motivation toward goal achievement and enables specialist referrals based on quality performance. The data will also highlight individual providers for preferred network alignment or physician champion roles to support initiatives.

2. Utilizes Episodes of Care to Engage Specialists and Share Savings: Utilizing shadow bundle data can better facilitate collaboration and gainsharing arrangements between ACOs and participating specialists. For example, ACOs working with specialists can utilize shadow bundle data to eliminate unnecessary post-acute utilization for their episodes by forming a narrow post-acute network of high-quality facilities to help generate better patient outcomes and savings to Medicare. Integrated workflows and data sharing related to shadow bundles help ensure a specialist’s active participation and commitment to delivering high-quality care. Additionally, the ACO can leverage quality and cost data to develop gainsharing arrangements that adequately reward and encourage specialists' ongoing engagement.

3. Enables a More Wholistic Look into the Patient’s Journey: Historically, specialists may not have had access to data that would allow them to see the full episode of care following a procedure or hospital discharge. Shadow bundle data affords the opportunity for specialists to see their patient’s journey once discharged and can incent them to improve patient satisfaction and quality of care outside the four walls of the hospital. Additionally, implementing a shadow bundle for a specific clinical area can focus efforts on improving care for a particular population that can become scalable to other conditions or procedures.

4. Promotes a “Practice Makes Perfect” Approach: Shadow bundles may grant ACOs who have not historically participated in bundles the opportunity to “practice” prior to the release of a CMS mandatory model in 2026. CMS has indicated that it plans to release a mandatory episodic payment model following the conclusion of the BPCI-A model – meaning hospitals in certain regions may soon be required to participate in bundled payments.

Premier has long advocated for Shadow Bundles of Care.

While Medicare Shared Savings Program (MSSP) and ACO REACH participants are already taking steps to set their organizations up for success in a value-based payment environment, bundled payment models can not only work in parallel with these programs, but also amplify the work by aligning specialists within the ACO.

The shadow bundle strategy appeals to participants because it allows them the flexibility to design and develop bundles that can best incentivize their primary care and specialist physicians within their ACOs. The role of episode-based payment models must complement, not compete, with the work done by ACOs.

Healthcare leaders need to understand if a shadow bundle is an appropriate fit for their ACO model. To do so, they must evaluate the need for further specialist engagement, survey the market to identify which clinicians are engaged in bundles, and understand which primary care and specialist physicians are interested in partnering to ensure they have the buy-in to be successful. And for any bundled payment program to achieve quality improvement and cost savings, it also needs the capabilities to address post-acute and ambulatory challenges and opportunities.

Premier offers a wide range of expertise in bundled payment model readiness, preparation, development and implementation. Contact BundledPayment@premierinc.com to learn more.