The new BPCI Advanced bundled payment model means those who invested in the former mandatory bundles didn't throw their money down the drain.
When the Centers for Medicare & Medicaid Services cancelled or scaled back its mandatory bundled payment models last year, many healthcare providers feared the investments they made to prepare for these models might be wasted.
But there's plenty to like about the new voluntary Bundled Payments for Care Improvement (BPCI) Advanced model for organizations that had invested in value-based care models.
In BPCI Advanced, participants will be expected to redesign care delivery to keep Medicare expenditures within a defined budget while maintaining or improving performance on seven specific quality measures, says Tobin Lassen, chief knowledge officer with Global Healthcare Alliance in Houston, which has experience helping hospitals, health systems, and physicians manage bundled contracts with both commercial and government payer sources.
The quality measures, the first two of which apply to all clinical episodes (the others are for specific ones) are:
- All-cause hospital readmissions
- Advanced care plan
- Perioperative care: Selection of prophylactic antibiotic: First or second generation Cephalosporin
- Hospital-level risk-standardized complication rate following elective primary total hip arthroplasty and/or Total knee arthroplasty
- Hospital 30-Day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery
- Excess days in acute care after hospitalization for acute myocardial infarction
- AHRQ patient safety indicators
Participants bear financial risk, have payments under the model tied to quality performance, and are required to use electronic health record technology that passes CMS certification.
Meeting those requirements qualifies the model as an Advanced APM, which is significant, at least partially, because physicians who participate in one will be exempt from MIPS reporting requirements.
"The 32 types of clinical episodes in BPCI Advanced add outpatient episodes to the inpatient episodes that were offered in the Innovation Center's previous bundled payment model (the Bundled Payments for Care Improvement initiative), including percutaneous coronary intervention, cardiac defibrillator, and back and neck except spinal fusion," according to CMS' website.
Going forward, it will be important for such programs to create and monitor the measures they track, says Lassen.
"CMS has seven quality indicators in this. Your organization will be judged on them, and your bonus will be contingent on them, not just on the cost," he says.
The new voluntary bundles can pay off for five reasons, he says:
1. Investments haven't been wasted
The introduction of the new BPCI Advanced model underscores that those who have already made an investment did not throw their money down the drain, says Lassen. The introduction of specific voluntary bundles means those who want to move further down the risk curve can do so, and at their own pace.
"A lot of people made a lot of investments and none of that goes to waste," says Lassen. "You can continue to deploy that capital."
That means investments in outpatient care networks or integrated electronic medical records, or team-based healthcare, such as multidisciplinary rounding to identify gaps in care that may lengthen stays, could still deliver ROI, if the organization is willing to take on risk through the voluntary advanced payment models.
2. Comprehensive bundles
Lassen advocates applying for and participating in a comprehensive and diversified group of bundles instead of just cherry-picking high-risk conditions.
That includes adding outpatient bundles, which represent three of the 32 available bundles under BPCI Advanced, and helps an organization move more quickly from a largely fee-for-service model to a value-based one.
"I wish there were more [bundles]," he says. "This expands program size and allows for opportunities for equal or better outcomes in the less expensive settings. Also, we see a lot more hospital-payer-physician relationships centered on those outcomes."
3. Physician involvement
The new bundle offers opportunities for physicians to get involved, a critical constituency to making bundling work, says Lassen, based on his commercial bundling experience. The BPCI Advanced bundles are not just hospital-driven or convener-driven.
"Now, nonconvener groups, including physician groups, can bear or apportion risk," he says. "What's so good about it is that not being hospital-driven, physicians can choose whether to be aligned with the hospitals, because they really control the care. It's never been that way, so physicians should be very happy."
4. No MIPS!
Although a certain portion of their work must be in the advanced model to get the bonus, now that physicians can participate in upside and downside risk through BPCI Advanced, they will not have to do MIPS reporting.
Lassen says looking at total investments required to do the MIPS reporting and Medicare adjustments through 2026, he's not so sure MIPS offers a good risk-return probability anyway.
"They don't have to worry about that if they participate in BPCI Advanced models," he says.
5. Better patient engagement
The BPCI Advanced program is based on patient-centered care, navigation, and transparency, says Lassen.
"When we do our direct-to-employer bundled programs, we lead patient participation through that whole process, and it's key for [clients], because it can get quite complex. You need to be able to navigate the patients through it."
Focus on outcomes
One issue with the new voluntary program is that performance measures are still largely process-oriented, he says, as opposed to true outcome measures that create value for the patient.
Some of the commercial bundles Lassen has experience with are more outcomes-based, and he predicts BPCI Advanced or its successors will migrate toward that goal over time.
As an example of the power of outcomes-based measurement, one commercial bundling program Lassen worked with included the use of a provider-created database that tracked multiple participants for spinal procedures for three years, following outcomes.
"At this point, based on that database, they can predict the likelihood of success for a spinal intervention procedure," he says. "That's where we're heading on the commercial side—especially those who can track this data over time with that level of sophistication."
The BPCI Advanced portal closes March 12, so those who want to participate will have to decide their risk appetite and apply quickly, Lassen says.
The next application period won't start until January 2020.
Philip Betbeze is the senior leadership editor at HealthLeaders.