Bundled Payments

The Department of Health Care Policy & Financing (the Department) has adopted innovative alternative payment and delivery models that support transition from traditional fee-for-service (FFS) payments to value-based payments. The bundled payment program is offered to providers caring for Health First Colorado (Colorado's Medicaid program) members. Bundled payments involve providing a single, comprehensive payment that covers all the services within an episode of care.

Under a bundled payment model, participating providers are only responsible for outcomes of the episode. These providers hold limited risk for staying within the designated budget threshold and are eligible for shared savings when the threshold is not exceeded. Bundled payments are designed to align incentives for providers and encourage collaboration to improve the quality and coordination of care across care settings. The approach aims to reduce silos in a member's care experience and create efficiencies that lower costs. This results in improving the quality of care a member receives throughout the episode and ultimately leads to better health outcomes.

Episode of Care: Asthma

Under Construction

Program Overview

  • Program Specifications
  • Asthma Definition

Episode of Care: Breast Cancer

Under Construction

Program Overview

  • Program Specifications
  • Breast Cancer Definition

Episode of Care: Maternity Care

Perinatal mortality in the United States continues to increase and the issue has gained attention from health care providers, public health officials and policymakers. Forty-five percent of babies born in Colorado during 2018 were born to mothers enrolled in Health First Colorado or Child Health Plan Plus. According to the Colorado Department of Public Health and Environment (CDPHE), there were 94 pregnancy-associated deaths between 2014 and 2016. The pregnancy-associated mortality ratio was 47.4 per 100,000 live births during 2016 (Colorado Maternal Mortality Prevention Program Legislative Report 2014-2016, P. 18, 2020). Improving maternal health is a priority for the State of Colorado, therefore the Department is focusing its first episode-of-care bundle on maternity care.

The Maternity Bundled Payment Program covers all prenatal care, care related to labor and delivery, and postpartum care for the parent and their baby. Obstetric care providers serve as principal accountable providers because of their partnership with the patient and their ability to influence the episode. These principal accountable providers will have an episode budget calculated based on their historical claims data.

Typically, in bundled payment programs, principal accountable providers share in upside and downside risk for the episode. However, the Department will offer upside-only during the pilot program's first year. This approach allows the providers time to develop clinical pathways to improve a pregnant person's care experience and to prepare for the program's second year when downside risk is introduced.

The Maternity Bundled Payment Program launches on Nov. 1, 2020.Episodes submitted during the performance period will be retrospectively reconciled against the budget. In subsequent program years, episodes will be reconciled on a rolling semi-annual basis. Principal accountable providers (PAP) will receive shared savings if an episode remains within the designated threshold and quality goals are met. Providers will be liable for partial risk if the episode exceeds the threshold.

Read the Frequently Asked Questions (FAQs) and contact Trevor Abeyta, program lead, at trevor.abeyta@state.co.us.

Program Overview

 

For information concerning Bundled Payments please contact: Trevor.abeyta@state.co.us