November 15 2018

BPCI Advanced Fast Facts

We talk a lot about how to be successful in bundled payment models on this blog. But in the coming weeks, we’re going back to basics. We’ll be talking about the mechanics of bundled payments, the theories behind them, and the challenges and opportunities they present to organizations engaging in the shift to value. This week we’re covering BPCI Advanced or CMS’s Bundled Payments for Care Improvement Model. To start from the beginning of the series, read our first post.

On October 1, 2018, CMS’s largest voluntary episodic payment model, BPCI Advanced (Bundled Payments for Care Improvement) went live. The program will test 32 clinical episodes and, like previous models, incentivizes providers to reduce costs while maintaining or improving the quality of care provided.

10 Fast Facts on BPCI Advanced:
BPCI Advanced is the second iteration of Medicare’s voluntary Bundled Payments for Care Improvement program and is built on the success and learnings of BPCI Classic.

  1. Voluntary opt-in
  2. Single retrospective bundled payment + one risk track with 90-day clinical episode duration
  3. 29 inpatient clinical episodes; 3 outpatient episodes
  4. Qualifies as Advanced Payment Model
  5. Most complex case-mix adjustment methodology to come from CMS
  6. Target price is calculated per episode
  7. The baseline shifts every model year
  8. CMS’s PAT (peer-adjusted trend) Factor methodology requires that a program participant’s rate of improvement must be better than their peers’ to earn a bonus
  9. PGP target price is based on hospital performance
  10. Participants are eligible for a five percent (5%) increase in professional fees

HURDLES FOR BPCI ADVANCED PARTICIPANTS
BPCI Advanced is likely to be one of the more difficult programs to manage performance under. Not only did CMS step up their game on case-mix adjustment, but the clinical episodes are more complex, and the program takes into account peer performance. Unfortunately, many participants won’t have visibility into the data driving these factors until it’s too late.

Where BPCI-Classic case-mix adjustment was based on the DRG, BPCI Advanced uses more than 100 factors, including demographics, DRG, HCC severity, AMC status, and recent resource use, to adjust for patient complexity.

Additionally, unlike previous programs that calculated a DRG-level target price, BPCI Advanced target prices are assigned on a patient-by-patient basis, based on the presentation factors of each individual patient receiving care.

The target price you receive from CMS is based on your historical patient population and in effect, retrospective.  The actual target price of a patient who presents on admission could be vastly different. Without the ability to replicate CMS’s methodology for target pricing, you’re essentially flying blind.

TECH’S ROLE IN BPCI ADVANCED
As we’ve discussed in previous posts in this series, many providers are turning to technology to help successfully navigate their bundled payment programs. Analytics for risk-adjustment, engagement apps to keep tabs on patients, program diagnostics, and market analyses are just a few examples of ways providers are using technology to aid their transition to value. Unlike other retrospective bundles, though, static analytics won’t cut it this time. The key to managing success in BPCI Advanced is real-time data – and data that clinicians trust.

For more information about BPCI Advanced, check out our ebook.

Sources
https://innovation.cms.gov/initiatives/bpci-advanced
https://www.healthaffairs.org/do/10.1377/hblog20180131.50449/full/
https://jamanetwork.com/journals/jama/fullarticle/2553001

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