Bundled Payment

Bundled payment model begins accepting additional applicants

May 9, 2019 3:55 pm

April 30—Following early withdrawals, the largest voluntary bundled payment program is offering a last chance for new participants to sign up.

The Centers for Medicare & Medicaid Services (CMS) recently opened enrollment for the second cohort of the Bundled Payment for Care Improvement Advanced (BPCI-A) program. The new cohort of participants will begin in January 2020, the third year of the five-year model.

The model creates a two-sided risk payment for hospitals, physicians and post-acute care providers based on the cost and quality of care during a 90-day episode. Participants in the model also qualify for the 5% bonus under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) physician payment system.

The new application period had several changes to BPCI-A, including:

  • Choice of 37 (33 inpatient, four outpatient) potential clinical episodes, up from 29 inpatient episodes and three outpatient episodes
  • Addition of total knee joint replacement as a multi-setting episode
  • Creation of optional alternate quality measures

The alternate quality measure set will allow participating providers to choose five measures, compared with seven in the existing administrative quality measure set. The specific new quality measures have not yet been released.

Additionally, CMS will make more-recent data available. CMS offered original applicants their Medicare clinical data from 2013 through 2016, while the new data will cover October 2014-Septmber 2018.

“The inclusion of outpatient total knee makes sense,” said Gina Bruno vice president for clinical strategy for naviHealth, which manages 150 hospitals across 12 health systems in BPCI-A. “It is very consistent with what CMS has [said] over time about total knee replacement in the ambulatory setting.”

How the changes could affect participants

The biggest impact on potential applicants could come from the changes in quality measures and target pricing.

“Many participants raised concerns about the quality measures for Model Years 1 and 2,” Bruno said.

For instance, problems arose with the advance care planning quality measure due to acute care hospitals’ difficulty ensuring that advance care discussions had occurred with patients in the nine months prior to their procedure.

Providers “may or may not know that other discussions have taken place, especially if that discussion took place six months ago” between patient and primary care provider, Bruno said.

CMS issued additional guidance in recent months for situations where patients declined to have such discussions.

“It may be that CMS is looking to provide additional flexibility in the quality measures based on the feedback they heard,” Bruno said.

She was hopeful the new quality measures would be a boost for participants as they strive to redesign care processes.

The new data and target pricing will be available to both new and continuing participants.

“This data will really capture in earnest some of the improvements that have been made through prior models,” Bruno said.  

Some chose to depart

The new enrollment period followed the March departure from BPCI-A of 117 hospitals (14 percent) and 135 physician practices (19 percent) among the 1,299 hospitals and practices that joined for the model’s Oct. 1, 2018 start date. The departures amounted to one in seven participants.

In addition to accepting new enrollees, the latest enrollment period allows current participants to add episode initiators or restructure their applications.

“You may see some participants — or episode initiators — that chose to withdraw in March use this opportunity to reapply,” Bruno said. The application period also may lead existing participants to expand their involvement, she said.

Like the initial application period, the new enrollment option allows prospective providers to obtain their Medicare clinical data without committing to enter the program.

CMS says it will release by September the historical data and target pricing it will use in the final three years of the program. That could present a time crunch for organizations that will need to decide by the end of the year whether to continue into full participation. 

Lessons learned so far

Although CMS has not yet issued initial performance evaluations for providers in BPCI-A, program data from earlier bundled payments indicated providers were gaining much of their spending reductions by redirecting patients to lower-cost post-acute care settings.

But Bruno has seen BPCI-A participants look much more holistically at patient care, including a focus on readmission reductions over the 90-day care episodes.

 “You’re starting to see many providers think about how to best care for patients across models who may have complex and chronic needs,” Bruno said. “That is a much more pronounced focus for [BPCI-A] than we saw in prior models.” 

Early steps for organizations interested in joining BPCI-A include:

  • Identifying key stakeholders, such as clinician and physician champions for the program
  • Thinking about clinical workflows and new approaches to use
  • Learning about the program and talking to peer hospital participants

A lagging focus on those areas can impact organizations’ success in the program, Bruno said.



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