“We want to pay for outcomes, not process ... We need results, American patients need change, and when we need mandatory models to deliver it, mandatory models are going to see a comeback.”
Secretary of Health and Human Services Alex Azar
HHS Secretary Alex Azar, in a speech at a primary care conference in November, reaffirmed that the administration embraces value-based payment models. He told healthcare providers to expect more bundled payment models in the future, saying CMS will be revisiting some of the episode payment models it halted in 2017 and is “actively exploring” episode-based models in other areas, including a mandatory bundle in radiation oncology.
With mandatory programs on the horizon, the voluntary Bundled Payments for Care Improvement Advanced (BPCI-A) program offers early access to data and valuable experience in redesigning patient care.
HORNE Healthcare worked with an early adopter to explore alternatives and navigate decision points along the way toward BPCI-A participation. HORNE also helped this acute care hospital manage the complex application process, aggregating information from multiple departments and from CMS to help executives and service line managers with important participation decisions.
To Apply, or Not to Apply?
The first decision point came early in 2018 when BPCI-A opened to applicants. The hospital’s leaders saw a chance to further solidify relationships with employed and independent physicians and to prepare itself and its providers for the upcoming mandatory bundles. Knowing that hospital could apply without obligation to participate was a plus, and access to valuable CMS episodic data, especially data on healthcare spends outside the inpatient stay, was also a strong consideration in determining whether to apply.
To Convene, or Not to Convene?
Next, the hospital’s leaders considered whether to participate as a “convener,” “non-convener” or “episode initiator” (EI). After weighing the facts and the projected financial impact for itself and key physician groups, the hospital chose to be a convener.
Which Clinical Episodes?
The next step was to analyze claims data. BPCI-A applicants can submit a Data Request and Attestation form asking CMS to produce claims data. CMS delivered the data in July, four weeks before the August 8 deadline to select clinical episodes.
Using actuarial and analytic resources, HORNE analyzed the historical performance of the hospital and its physician partners. Based on this analysis, the hospital identified episodes with the greatest upside potential.
Which Physician Groups?
Next, using HORNE’s analytics, the hospital identified high-quality, cost-effective physician groups as partners.
Early communication with the physicians was critical. In partnership with HORNE, the hospital’s leaders supplied physicians with information about the program, how it would benefit them, and what data and resources it would require.
How Do We Split the Pie?
Participants in any bundled payment model must agree on how to apportion upside potential and downside financial risk. HORNE worked with the hospital’s executive team to design a model for giving financial incentives to adapt behaviors and redesign care processes.
How Do We Keep Patients Out of the Hospital?
Since program success or failure requires caring for patients in the most cost-effective setting, the hospital focused on the costliest aspects of care. During regular meetings, a team discusses BPCI-A patients and tracks their care across the entire 90-day episode. The hospital is working closely with its network of post-acute providers to monitor quality of care and discharges. Care coordinators interact with patients to ensure they attend follow-up physician visits and heed post-procedure protocols.
How Are We Doing?
Another critical decision will come in March 2019, when CMS will let participants retroactively withdraw from clinical episodes or EIs (or both). This risk-free off-ramp gives participants five months to refine care processes and analyze data before deciding how to proceed in the program.
Each month, CMS provides participants with claims data to gauge performance. This began in October 2018, and the first two month’s data indicates that the hospital is doing a good job of managing costs and identifying outliers. This monthly data will help participants make course corrections as necessary. If the data shows positive trends, the hospital can also consider adding clinical episodes during the period from January 2020 to December 2023.
Considering Applying for 2020?
If your hospital, health system or physician practice is thinking of applying in 2019 to participate in BPCI-A starting in 2020, consider these factors:
- Access to data. Without data analytics, choosing clinical episodes and EIs is a shot in the dark. BPCI-A participants must expend resources to analyze the data and make good decisions.
- Appetite for care redesign. Episode-based payment programs require a commitment to care redesign. If you participate as a convener, your EIs must embrace that mandate. And as a convener, you must hold the EIs—and your own organization—accountable for delivering quality, low-cost care.
- Openness. You’ll share information about your organization and EIs. If you join a convener as an EI, you’ll be expected to open your books and processes to them.
- Time. Requesting and aggregating information from multiple departments to complete the extensive application would challenge any organization. Afterward, ongoing program management and results analysis will take significant resources.
If you find the bundled payment model daunting, you’re not alone. However, BPCI-A participants are seeing early success in the program, and CMS is reaffirming its commitment to shift the bulk of its payments to value-based models. The smart play is to get on board.
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