Has it been four months already? That’s when the first performance period began for CMS’ latest bundled payment model, BPCI Advanced. Now participants are less than a month away from the March 1st deadline.
By March 1st, they can drop participation in any (or all) of the 32 clinical episodes without penalty or financial risk. This “get-out-of-jail-free card” expires soon. Here are four key elements your organization should consider.
1. Performance trends and comparison to target price
CMS has only released a few months of claims data with very few, if any, bundles at a full 90-day maturity. In order to project a bundle’s total spend to full maturity, we have developed bundle maturity models to estimate a final comparison to target price based on limited data. We also look at trends in key performance indicators like discharge-to-home and the anchor allowed.
2. Qualification for APM status
Many organizations are hoping to achieve Qualifying Participant (QP) status under an Advanced Alternative Payment Model (APM). This enables them to receive an automatic 5 percent payment bonus. Otherwise, they would be subject to Medicare’s Merit-Based Incentive Payment System (MIPS) reporting requirements and payment adjustments.
Our suggested approach is to remain as conservative as possible if QP status is a desired strategic goal. Here’s an example. As you evaluate monthly CMS data, compare total allowed amounts for physicians on your QPP List to your organization’s total Medicare allowed for the same list of physicians over the same time period. Aim for a goal ratio of 60–65 percent (at least 10 percent above the QP threshold for 2019).
3. Successes in developing clinical pathways
In BPCI 1.0, the vast majority of achieved savings were associated with:
- Decreases in SNF spending
- Decreases in readmissions
- Increases in home health spending
Driving results in these areas requires refined clinical pathways. These pathways should appropriately place patients post-discharge. They should also maintain patient engagement throughout the continuum of care into the home.
4. Organizational appetite for risk
Some organizations selected bundles with significant target price advantages. Others joined to gain experience with this growing alternative payment model and the new operational challenges it brings.
For the latter organizations, the key decision-making criteria may be appetite for risk. In other words, how much of a potential loss could the organization take on while maintaining its current bundle selection?
In contrast to the first bundle payment program, CMS is doing less to limit each participant’s exposure to risk. Whether gaining experience in this program is worth it not, we recommend seeking reinsurance to cover any excessive losses that could occur. Some financial protection is important, particularly if you are looking at your participation in BPCI Advanced as an investment.
The above considerations are critical for the upcoming March decision. But they are also valuable in the business management of any selected bundles. You can read a more detailed version of this blog here. Or to connect with a consultant about BPCI Advanced, the 2020 application, and how Optum can assist your organization with bundle payments, via our website.
About the Author
Jordan Holland, MBA
Director, Provider Enterprise Services
Jordan Holland has been with Optum/The Advisory Board for more than five years. He partners with clients to provide clinical and financial modeling and analysis, business intelligence creation and optimization, and strategic decision-making on financially sustainable population health activities and programs. Mr. Holland has historically focused on clients with needs related to value-based transformational change, strategic asset growth and expansion, and managing clinical variation within the health system.