Evaluation of a bundled payment system in the National Breast and Cervical Cancer Early Detection Program: Colorado's Women's Wellness Connection

The Women's Wellness Connection (WWC) program is administered by the Colorado Department of Public Health and Environment (CDPHE) as part of the Center for Disease Control and Prevention's (CDC's) National Breast and Cervical Cancer Early Detection Program (NBCCEDP). WWC provides free breast and cervical cancer screening and diagnostic services to low-income, uninsured, and underserved women across Colorado. Screening and diagnostic testing services are provided through a network of 45 clinical providers, including local public health departments, Federally Qualified Health Centers, non-profit health centers, safety net clinics, and hospitals. In 2009, CDPHE developed the Bundled Payment System (BPS) and began paying providers predetermined reimbursement levels based on expected costs of a set of breast and cervical cancer screening and diagnostic services. BPS provides increasing levels of reimbursement for escalating case complexity for screening and diagnosis ranging from $50-$1445 across four levels for breast services and $50-$480 for cervical services. Researchers from ICF International, CDPHE, and CDC conducted an evaluation of BPS to assess effectiveness in improving timeliness and completeness of care and impacts on costs. Using a mixed-methods approach of analyzing quantitative data from WWC's electronic data management and public health surveillance system used to track clinical service delivery and reimbursement and conducting key informant interviews with providers, the research team aimed to understand the clinical, data quality and financial impacts of BPS on breast and cervical cancer screening and diagnostic services. Findings suggest that compared to the former capitated payment model, BPS is associated with increased likelihood of timely and complete patient care and follow-up for those with abnormal breast cancer screening results. This effect was not observed for abnormal cervical cancer results. In addition, BPS has no differential effect on clinicians' ordering practices; in other words, bundled payments did not appear to incentivize unnecessary diagnostic services among WWC providers. Findings related to costs will also be discussed. When implemented in combination with policies mandating data entry timeliness and standard lost-to-follow-up procedures, bundled payments for breast cancer screening may help ensure complete and timely service provision and improved data quality for public health programs. Further, the bundled payments model of reimbursement has the potential to assist other NBCCEDP grantees who are interested in moving away from a capitated or fee-for-service model.