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The new Bundled Payments for Care Improvement Advanced (BPCI Advanced) program from CMS will generate a huge amount of data that hospitals can use to improve quality, but exactly what data is coming and what do you do with it?
CMS has said that it intends to distribute target prices and the associated data to BPCI Advanced applicants in May, says Keely Macmillan, BPCI general manager with Archway Health, a software company in Watertown, MA. CMS also is expected to release more information on how it will score providers on quality metrics, as well as the new pricing methodology.
“When providers get the data in May, there are a lot of things to look at. It’s important to understand the data across episodes and also along the continuum of care, so they can look for the opportunities for success in this program,” Macmillan says. “There may be an opportunity to start developing a preferred provider network and identify the high value post-acute care facilities, for example.”
BPCI Advanced is a single retrospective bundled payment program covering services within a 90-day clinical episode. A clinical episode is defined as beginning with an inpatient admission for an inpatient procedure or the start of the outpatient procedure, and the episode continues for 90 days after discharge or the procedure.
The program is voluntary and healthcare providers can choose to participate in up to 29 inpatient clinical episodes and three outpatient clinical episodes. (More information on BPCI Advanced is available on the CMS website at: https://bit.ly/2mcB3me.)
Healthcare providers are showing interest in the BPCI Advanced program because it offers the chance for increased revenue and limits how much money can be lost if goals are not met, Macmillan says. BPCI Advanced also qualifies as an Advanced Alternative Payment Model (APM) under the Quality Payment Program created by the Medicare Access and CHIP Reauthorization Act (MACRA). Because they take on financial risk with BPCI Advanced, participating physicians can earn MACRA’s Advanced APM incentive payments.
The data also can be useful in persuading physicians to participate in the program, Macmillan says, and that is key to successful BPCI participation. Hospitals also can use the data to develop their documentation and coding structures for the program, which are more important in BPCI Advanced than they were in the first iteration of the program because the risk assessment and quality scoring all are tied to claims-based metrics, she explains.
“Providers will get data from all 32 bundles, so you can have specialists prepared to look at this data and tell you what it means, how you stand against it at this time, and what will be necessary for you to meet the targets,” Macmillan says. “You can use the data available to you now to go ahead and determine your benchmarks against your peers, and look for the levers of change that might apply. That might be readmissions, opportunities for standardization of care, improving relationships with other providers.”
The target prices for the bundles will be a key determinant in which bundles are appropriate for participation. When the target price is reasonable for an area in which the provider already excels or one with goals that seem attainable, there is significant potential for increased revenue, Macmillan says.
“For hospitals, it’s well known that Medicare’s fee-for-service is notoriously low and tightening up all the time. This is one opportunity to improve fee-for-service revenue, and for a lot of hospitals it will be the only opportunity” she says. “The other benefit from this program is that CMS will give you all this historical data up front, and if you participate you get updated data monthly. This is all data that you wouldn’t get otherwise.”
In addition to the potential financial benefits, BPCI Advanced also can promote quality improvement.
“One of the differences between BPCI and BPCI Advanced is that your performance on quality measures is going to impact your shared savings or shared losses. There are seven quality measures for the first two years, and then CMS plans to introduce more in 2020,” Macmillan says.
“The good news from an administrative burden perspective is that the quality measures for the first two years are all claim-based, so there is no additional quality reporting requirement,” she adds. “They’re all going to be calculated on the back end based on claims processed by CMS.”
Macmillan notes that outcomes measures will be weighted more heavily than process measures, and CMS has noted that the advance care planning metric will be applied to all 32 bundles.
Most Medicare beneficiaries do not have an advance care planning metric in place, Macmillan says.
“That’s going to be a big change for most providers to be scored on that advance care planning metric, and I suspect it will have to be one of the first things to address when an organization decides to participate in BPCI Advanced,” she says.
Healthcare providers have until Oct. 1 to analyze the data and determine which BPCI Advanced bundles to participate in, if any. Macmillan expects substantial interest from providers in participating in the BPCI Advanced program, partly because providers are now more experienced with bundling and accountable care organizations.
“There have been some providers who evaluated BPCI the first time around and passed on the opportunity, and there were some who participated but dropped out. I think some of those providers will be attracted to the BPCI Advanced program now because of some of the changes made to the program.”
Financial Disclosure: Author Greg Freeman, Editor Jesse Saffron, Editor Jill Drachenberg, Nurse Planner Jill Winkler, Editorial Group Manager Terrey L. Hatcher, and Consulting Editor Patrice Spath report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study.