Shadow Bundles – How to Interpret and Utilize the Data

Recently, many of my ACO clients asked about the Shadow Bundles that are in their ACO portal files. What to do with them, how to use them, who are the comparison ACOs, and what’s next are the typical discussion points. Also, “what are these?” was one of the first and most repeated questions I was asked.  Having done research and reviewing the data included, here are some thoughts on the Shadow Bundles.

CMS uses bundled payment models for specific episodes of care with a fixed price set per type of episode of care. An episode starts on the hospital admission date or triggering event (for outpatient or multi-setting clinical episodes) and ends 90 days after the triggering event or the patient dies. The bundle is the total cost of care for that period and includes most all the care provided in this time. In the new TEAM model for hospitals (Transforming Episode Accountability Model) that is replacing the Bundled Payments for Care Improvement Advanced (BPCI-A) and Comprehensive Care for Joint Replacement models, the specific bundles are grouped by the type of condition being treated such as cardiac, bone/joint, or kidney as examples. There are 29 inpatient, three outpatient, and two multi-setting clinical episodes that are covered by the upcoming TEAM model that hospitals must use. What the ACO REACH and MSSP ACOs receive is a “Shadow Bundle” to review their aligned patients’ locations of care, costs, and outcomes in comparison with other ACOs across the country.

There are many worksheets in the shadow bundle packet and there is much data available. However, while the data is “good”, it should be reviewed with caution. The main concern with shadow bundles is that for many ACOs, the patient population measured in the shadow bundle is small enough to be statistically unable to give the most accurate data for making inferences. For example, consider this example of an inpatient bundle breakdown for cellulitis:

For this measure (and all measures) there is drill down to the specific inpatient hospital that the patient received care and additional metrics such as total cost of the episode, what types of post-acute care received during the 90-day period including readmissions and death, comparisons to how your ACO compares in costs to all ACOs nationwide, and clinical severity of the patients. But look at that total number of patients.  Due to how ACOs are often structured, it is highly unlikely that all these patients had the same provider or inpatient hospital. Furthermore, with only six (or four, or 20) episodes, one outlier can skew your results in either direction due to the low confidence of drawing conclusions from statistically insignificant numbers.

There is important data for ACOs in the Shadow Bundles, however. Post-anchor spending is the post-acute period spend on home health, ED visits, provider visits, acute rehab/long term acute care (LTAC) inpatient care, and/or skilled nursing facility (SNF) care. Comparing your ACO’s spend and where the spend is occurring can help your ACO with evaluating outcomes against spend for the variety of post-acute providers that are utilized by the patients. Depending on the volume of patients in the BCDI-A categories, you can compare the anchor/inpatient spending and outcomes as well and use this data to drive which acute care hospitals and specialists are having the best outcomes. Your team can also identify potential discharge planning concerns that need to be addressed if expensive interventions are used with poor outcomes at some facilities. An example of this is identifying if specific inpatient hospitals are using more acute rehab hospitals than others and comparing this to the national averages to see if this utilization is outside of the norm for specific BCDI bundle categories. Another example is to view the national averages for SNF length of stay and inpatient readmissions for a BCDI category to your ACO outcomes in these areas. It can lead to a review of which SNFs your patients are going to after inpatient discharge and an update of your network of post-acute providers.  When your outcomes and spend are better than the national average, there is opportunity for the ACO to use this data in contract discussions with acute care hospitals who will be responsible for the total cost of the episode of care. With the mandatory TEAM model being implemented starting in 2026, having data to show how your ACO can manage the patient’s post-acute period spend and outcomes is valuable for forging true partnerships with the inpatient hospitals.

In summary, there is excellent information in the Shadow Bundles that can give your ACO insight into how your network is caring for the aligned patients and where opportunities lie. Due to the small cohorts that most ACOs have for each bundle type, use caution with the exact numbers seen for percentages in outcomes and spend as outliers are more impactful and the numbers are often low confidence.

For more information about Shadow Bundles, or anything ACO-related, feel free to set up a quick meeting.

Author:

Carol Javens, RN, BSN, CHPN | Account Manager, Acclivity Health Solutions