Q&A with Remedy Partners Chief Medical Officer, Win Whitcomb, MD: How to optimize bundle selection in BPCI advanced

Can you provide a brief overview of the BPCI Advanced program and the benefits of participating?

Bundled Payments for Care Improvement (BPCI) Advanced is a new Advanced Alternative Payment Model that goes live October 1, 2018. It picks up where BPCI, which concludes September 30, 2018, leaves off in that it is a bundled payment model for Medicare fee-for-service beneficiaries. BPCI Advanced encompasses 32 different bundles, or episodes, which include an acute hospitalization and the 90-day period that follows (save for three outpatient procedure bundles, which include the procedure and the 90-day follow on period). It is a voluntary program where acute care hospitals and physician group practices may participate as ‘episode initiators’, assuming clinical and financial risk for patients during the episode.

Applicants are free to choose one of more of the model’s 32 bundles and then are committed to participate with those bundles for the first five quarters of the program, at which time they can change their selected bundles. The bundled payment is carried out retrospectively where Part A and Part B claims are summed; if total payments are less than an episode initiator-specific target price, the initiator may keep the difference; if total payments exceed the target price, the initiator must pay back the overage. Performance on quality impacts incentive payments. The model specifies seven claims-based quality measures, which yield a composite score that adjusts the amount of savings, or incentive payments, an initiator is entitled to (or losses an initiator incurs). Episode initiators may go it alone or participate with a ‘convener’ which may provide key services such as care management technology, analytics and reporting, care redesign expertise, networks of post-acute providers and sharing of financial risk.

CMS will be distributing data to BPCI Advanced applicants this month. What should providers be looking for in the data?

The data will contain Medicare Part A and B claims for each provider applicant mapping to the 32 BPCI Advanced episodes for the years 2014, 2015 and 2016, to include a target price for each of the 32 bundles. Applicants will be able to see the total spending represented by all 32 bundles and the total number of episodes. They will also be able to see, in the aggregate and for each bundle, major areas of spending during an episode, such as anchor hospitalization, readmissions, skilled nursing facilities, inpatient rehabilitation facilities, and spending tied to home health agency services, physician services, durable medical equipment, etc.

Applicants should evaluate areas where there is high spending, high variation, or both. Evaluation can occur at the aggregate level and by individual bundles (e.g., total joint replacement, heart failure, etc.). Because BPCI Advanced is a pay-for-improvement program, when selecting bundles applicants should prioritize bundles where there is opportunity for improved performance over the baseline period (2014-2016).

How can providers improve things like readmission rates and care coordination to be successful under this model?

Established practices that improve care transitions and reduce readmissions will translate well to BPCI Advanced. However, care transition practices that have evolved under 30-day readmission penalties associated with the Hospital Readmission Reduction Program may need to be re-evaluated because the BPCI Advanced episodes last for 90 days following anchor hospital discharge. Therefore, any readmission occurring during the 90 days will affect the program's success. This will place more emphasis on longer term follow up with patients' key physicians and other providers. One particular aspect of care coordination, namely selecting the optimal discharge destination based each patient's profile, will be important in achieving the judicious use of post-acute services, which account for a substantial portion of spending during an episode.

What else should providers consider to ensure they select the most strategic bundle for their organization?

Providers should look at recent changes in their local environment that may influence performance in some or all of the BPCI Advanced bundles compared to the baseline period. For example, new initiatives aimed at reducing readmissions or changing post-acute utilization should be factored in, such as new care coordination technology, a palliative care consult service, a heart failure clinic, or new home health agency capacity. Other questions that can uncover local changes versus baseline include: Have there been hospital closures or openings nearby that might affect patient mix? Are there new post-acute facilities, such as an inpatient rehabilitation unit, that might influence post-acute spending? Have there been changes to service lines or physician activity that may influence the volume of selected procedures? Each of these may signal a change in the opportunity to perform better than the baseline.

What investments will providers need to make in technology infrastructure and/or care redesign to be successful in BPCI Advanced?

Hospitals and physician groups initiating episodes will need to have the capacity to track, manage, and report on patient activity during all phases of an episode both at individual and aggregate levels. Technology that provides visibility into patient activity during the acute and post-acute portions of an episode, along with decision support tools targeted at key success levers in BPCI Advanced (for example, identifying readmission risk, post-acute network facilities, or discharge destination) help to case manage individual patients and to lead the overall program. Providers will also need to invest in care redesign capacity, which, for example, may include the ability to negotiate price on devices through bulk purchasing, utilize a post-acute network or arrange transportation to follow up appointments.

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