Providers Mull Options for BPCI Advanced

Michael D. Dalzell

This month, hospitals and physicians in the second wave of applicants to CMS’s Bundled Payments for Care Improvement Advanced (BPCI-A) model are deciding whether to take the plunge. In late September, CMS provided four years’ worth of claims data to applicants, who have until December 1 to look the information over and decide whether to participate in the program.

CMS hasn’t said how many organizations applied when the window was open last spring. But if anecdote is any gauge, enthusiasm for the two-sided risk model is high—likely, in part, because of changes to the program that take effect on January 1. 

The most salient of those changes was the addition of four inpatient episodes—seizures, inflammatory bowel disease, bariatric surgery, and transcatheter aortic valve replacement —bringing the total to 31. Major joint replacement of the lower extremity, the most popular episode selected during the first enrollment period in 2018, has been expanded to include outpatient knee replacements.

Another important change was the elimination of the 50% cap on reconciliation payments that could be shared with downstream providers. High-functioning practices that had the ability to manage care coordination, quality, and costs had viewed the cap as a financial disincentive to participate as episode initiators. “As organizations and individual practitioners become more mature in their programs, they rightfully look for the opportunity to be recognized for their contributions to patient outcomes,” says Gina Bruno, vice president of value-based care at naviHealth, a company headquartered in Nashville that helps provider organizations manage their participation in BPCI-A.

Top 10 episodes by participation, BPCI-A Years 1–2*

*Selected by providers that remained in the program after the March 1, 2019, dropout deadline. Years 1 and 2 cover clinical episodes that are completed by June 30, 2019, and Dec. 31, 2019, respectively.
AMI=acute myocardial infarction, CHF=congestive heart failure, COPD=chronic obstructive pulmonary disease, MJRLE=major joint replacement of the lower extremity, PCI=percutaneous coronary intervention.
Source: CMS, Episode initiators and clinical episode selections, Model Year 2, March 2019

The added flexibility in BPCI-A may contribute to an uptick in the number of those who ultimately sign up. In 2018, 1,590 provider organizations joined BPCI-A, but 295 dropped out when CMS gave them an escape hatch earlier this year—and that was before they had received any meaningful data on cost savings, losses, or episode costs. It’s not clear whether departing organizations lacked internal support or just weren’t ready for the program.

To that end, there are lessons new applicants can learn from the first cohort. “Applicants should be very focused on change management, internal coalition building, and communication,” says Bruno. Because BPCI-A covers only a small portion of most organizations’ services, she says, there’s a risk that applicants may underestimate all the work needed to align clinical, operational, administrative, and financial leadership in their support for the program.

Operational readiness counts for a lot, too. “It is imperative that organizations get really honest about their capabilities and their commitment in the clinical setting,” says Bruno, “because meaningful care redesign is going to drive the financial outcomes they hope to see.”

A final caveat: Beware of the law of diminishing returns. Most organizations that join BPCI-A will probably have had some experience with implementing value-based care, and for those that have gotten very good at reducing inappropriate utilization, being benchmarked against their own historical spending data gives them “a bit of a steeper hill to climb as they go forward,” says Bruno. “It’s a bit of a conundrum.”

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