Clarify Health: BPCIA MY4 Changes and Analysis

By the end of this week, CMS will ship refreshed baseline data to all participants in the Bundled Payments for Care Improvement Advanced (BPCI-A) program. The decisions that Hospital and Physician Group Practice (PGP) participants must make by mid-December have broad implications, especially as mandatory bundles from CMS become more of a certainty. In this two-part blog series, we’ll do the following:

  • Part 1: Summarize the MY4 changes, strategic implications, and why a proper Diagnostic using the CMS Data shipment is so critical
  • Part 2: Describe how Clarify has helped our customers achieve an average of $3,100 of bonuses per episode in BPCI-A to date.

Key Changes to BPCI-A for MY4 and their strategic implications

In a nutshell, CMS is implementing significant changes to BPCI-A for MY4, which will force larger-scale meaningful participation or an exit from the program.

Clinical Episode Service Line Groups (CESLGs)

  • Changes: Participants can no longer elect to participate in individual episodes, but must now commit to all episodes in a service line. The 35 episodes now roll into 8 different service lines.
  • Implications: Participants can no longer cherry-pick high-value episodes and must choose to potentially expand participation into new clinical areas. Therefore, it is critical to understand the financial implications, risks, and improvement opportunities across episodes and service lines when making participation decisions.

Removal of the Physician Group Practice (PGP) Offset

  • Changes: Physician Group target price will be equal to the Hospital target price, and will no longer be adjusted based on PGP historical performance against peers.
  • Implications: Removing the PGP offset will result in lower target prices for PGP’s that were historically higher-cost, and a higher target price for PGP’s that were historically lower-cost. Given PGP target price will equal the hospital target price, PGP’s must be very informed and strategic about how target prices vary across hospitals and where they choose to perform episodes.

The Importance of a Robust Diagnostic for BPCI-A Model Year 4

Given the above changes, a precise and robust diagnostic on the baseline data from CMS is that much more important for all. Organizations should be able to answer several questions in order to make a fully informed decision about participation:

  • How has my performance and efficiency on each episode type trended over the past 3 years?
  • How have my target prices changed over the past 3 years?
  • What were target prices for each individual episode, and where were outcomes driven by outliers versus operational efficiency?
  • What is my forecasted bonus/penalty in each service line and episode, and how does that project into 2021?
  • What are the top opportunities for performance optimization, given the risk-adjusted complexity of specific patients who I treat?

Clarify’s diagnostic answers the above questions using our advanced modeling and precise target price calculations on our industry-leading proprietary platform. The insights from the diagnostics we have run over the past 3 years for our BPCI-A participant clients have been critical in helping them enroll in the most high-potential episodes, and achieve an average of $3,100 in bonuses per episode.

Screenshot of Clarify Health BPCIA MY4 Diagnostic

Snapshot of Clarify Health’s BPCI-A Diagnostic

Want more information about Clarify’s BPCI-A Diagnostic? E-mail [email protected].

Our next post will describe how the combination of our BPCI-A diagnostic and management analytics have helped these organizations achieve ROI in the program.