Bundled Payments for Care Improvement-Advanced (BPCI-A) is one of the latest evolutions of value payment methodologies to come from the Centers for Medicare and Medicaid Services (CMS). The roots of BPCI-A are in the original bundled payment demonstration project, the Acute Care Episodes (ACE) program of 2009, which shares an underlying theme that a single, bundled payment for all providers for a defined episode of care will promote efficiency of care, coordination of care and improvement in the quality of care. CMS would like to see higher quality performance paired with lower expenditures in these identified patient populations.
BPCI-A is a voluntary program with a greater risk potential for the providers than seen in earlier projects. A successful BPCI-A program has many key ingredients. Among them are the support of the hospital administrative team and an appropriate pool of identifiable Medicare patients for the Clinical Episodes designated in the BPCI-A plan. Because payments under BPCI-A are explicitly tied to quality performance, success in the program depends on how well an organization can engage its clinicians in quality improvement initiatives. Therefore, two critical components are needed for BPCI-A to succeed: physician alignment with the BPCI-A program and real-time, actionable data on quality performance.
For physicians and other clinicians to improve on defined quality metrics, they must change clinical behavior in identified areas of opportunity. For physicians to change their behaviors, they must believe in the change. Consider education about how proposed clinical modifications are in the best interests of their patients. For example, healthcare organizations might show how adopting evidence-based clinical practices and standardizing clinical practices leads to better outcomes. Physicians must also accept that the proposed changes will be efficient for their practice and will ultimately lead to financial rewards based on their performance.
Identifying and involving physician leadership in this quality improvement endeavor is essential. Clinical leaders, with appropriate guidance, can encourage peers to adopt new clinical behaviors better than outsiders can.
The physician alignment conversation should also include the concept of value. Value is defined as quality divided by costs. Therefore, patients get the best value when clinicians try to provide the highest-quality care (as defined by identified objective metrics) at the lowest cost (most efficiently).
Another important point for alignment is that BPCI-A qualifies as an Advanced Alternative Payment Model (AAPM) under the Quality Payment Program. Participating physicians (and other clinicians) would, therefore, be eligible for potential increases in bonus payments under this program.
Acceptance from—and alignment with—physicians and other clinicians is needed for quality improvement and the success of the BPCI-A initiative. But another ingredient is also required.
As mentioned, real-time quality and process data on hospital and physician performance is critical in this process. The clinician must be presented with data that show his or her initial performance status on the BPCI-A defined quality metrics in order to find areas for improvement, both for the individual and the group. Also, clinicians must have regular access to this data during the initiative to constantly drive improvement on quality metrics.
Data that is real-time, or as near to real-time as is possible, is essential. Up-to-date data allows for more frequent, timely changes in behavior and more clinically relevant regular input, which the clinician needs in order to improve.
All clinicians should have regular, structured data feedback on quality performance at least monthly, in a user-friendly, actionable report. For best results, this data should be given at the physician level as well as the group, service line, and hospital levels.
Such feedback is even more important when “cognitive” clinical episodes (such as sepsis or COPD) are chosen for the BPCI-A initiative, as opposed to “procedural” clinical episodes (such as joint replacement or coronary artery bypass graft). Because of their defined, limited, and clearly identified elements, procedural clinical processes have been easier to change, whereas their “cognitive” counterparts typically have fewer clearly identifiable, modifiable pieces, making behavior changes more challenging. Cognitive clinical episodes therefore have an even more intense need for data.
Many groups have succeeded in previous bundled payment programs. To succeed in the more rigorous BPCI-A initiative, with its intense focus on quality and its higher risk, multiple different parts of the program must function effectively together. A program that addresses the two critical areas of physician alignment and access to data resources can look forward to significant progress that will benefit the clinicians, the hospital, and most importantly, the patient.
About the Author
Dr. Siegel is a senior executive, physician and attorney with extensive experience in both health system management and consultant roles. His proven record of success includes demonstrated expertise in physician alignment and integration, care across the continuum and risk management.