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BPCI Advanced: Apply Now,
Decide Later

by Amanda Brown, Manager, and Amanda Kueh, Analyst

CMS has opened applications for a second cohort of BPCI Advanced (Bundled Payment for Care Improvement-Advanced) participants in April.

This initial application step gets you valuable data, and time to decide whether to pursue participation. Advantages of applying include:

  1. No obligation to participate. You have time (likely until fall 2019) to decide whether to sign a participation agreement or give it a pass. Participation for this cohort will start in January 2020.
  2. The data that applicants receive is its own reward. Whether or not you ultimately choose to participate in BPCI Advanced, you will receive a trove of rich data that can be used to deepen the strategic understanding of your hospital, health system, or physician group, improve quality of care, and target care management efforts. Applicants can request and receive up to three years of claims data for Medicare fee-for-service beneficiaries who would have been included in all 29 inpatient and 3 outpatient clinical episodes attributed to the applicant or its potential Episode Initiators.

Once the claims data is cleaned, applying advanced analytics can provide answers to key strategic and care management-related questions, such as:

  • How does each physician contribute to the organization’s overall performance? Analysis can reveal episodes per physician, physician-level utilization by anchor trigger code, and readmission rates by physician and condition.
  • How is the organization positioned relative to other organizations? Relevant data includes historical performance vs. target price, and episode payments vs. region.
  • Where are patients who are leaving the network seeking care?You get information on each patient’s whole 90-day episode, not just the care provided in your hospital, so you can look at re-admissions by provider and facility to get a sense of how many cases stay with your hospital or health system. You can also see where patients go for post-acute care, even if facilities are out of network.
  • How does our quality compare with other organizations? Data on re-admissions by condition, average length of stay, and utilization by post-acute care facility can provide some basis for identifying bundles with potential quality issues.
  • Which patients/conditions would benefit the most from care management? Relevant data includes variation in LOS by condition, and variations in re-admissions rate and quality scores by physician and condition.
  • Which care pathways or first-discharge locations yield the highest savings? Valuable data include financial summary by bundle; cost of care per episode, by setting; and use of SNF, home care, and inpatient rehabilitation facilities by bundle.

Of course, the dataset also supports CMS’ purpose in distributing it: determining where the bundled payment opportunities lie for your organization, should you decide to pursue participation in BPCI Advanced.

  1. There is significant savings opportunity for participants. CMS’ evaluation of Medicare payments under BPCI from Q4 2013 through Q4 2016 showed that savings were achieved in the majority of the hospital-initiated clinical episodes relative to the comparison group.[1]

Veralon clients have achieved cumulative savings ranging from $1.4 to $13.3 million, with the majority of the savings stemming from reduced SNF utilization.

While there is downside risk in this advanced model, there is also a stop-loss provision. Gains and losses are capped at plus or minus 20 percent of the target prices for all episodes in which the organization is participating. Episodes that are cost outliers (above the 99th percentile) are excluded from all calculations.

  1. Your organization can gain experience in value-based payment on a limited scale with a well-defined population. It is easier to track specific episodes of care and identify savings opportunities with bundled payment than with a full ACO population. You can focus on the bundles that offer potential for saving, rather than participating in all 32, and you have the data to know where you stand among peers so that you know where to focus.

CMS does not intend to have additional enrollment periods for BPCI Advanced in 2021 or 2022, so this may be the last chance to take advantage of the ability to obtain this data (and to participate in the program, should you make that decision). The application is relatively easy; you need to submit a Data Request and Attestation (DRA) form with the completed application specifying the information you want.

While we encourage everyone to apply to get the data, you should consider your circumstances carefully and do a thorough analysis of potential savings opportunities before committing to participate. Our article in HFM highlights five of the critical issues.[2]

By taking advantage of this no-obligation application, you are taking a step to get your foot in the door with value-based payment, and at the very least gaining insight into your delivery system and market.

[1] The Lewin Group, “CMS Bundled Payments for Care  Improvement Initiative  Models 2-­4: Year 5 Evaluation &  Monitoring Annual Report,” Prepared for CMS, October  2018.

[2] John Harris, Molly Johnson, Amanda Brown, “5 Critical Issues for BPCI-A,” HFM June 2018.