After much anticipation, and as promised in the recent cancellation of three new mandatory bundled payment models, the Centers for Medicare & Medicaid Services (CMS) announced on January 8, 2018, the next round of voluntary bundling to be called Bundled Payments for Care Improvement (BPCI) Advanced. The Request for Applications (RFA) is due March 12, 2018, and applicants should be prepared to go live by October 1, 2018. So after a long delay, the timeframe is now short for BPCI Advanced bundlers to frame out their plans and to assemble partners. The CMS roadmap lays out the full schedule.
As expected, the new model builds off the basic existing episodic structure of BPCI, but it also contains some important changes. From our perspective, among the most important of these changes is that post-acute providers will no longer have the ability to initiate episodes (currently known as Model 3). This is disappointing given the prominence of Model 3 in current BPCI, but not completely unexpected given CMS’ need to implement an Advanced Alternative Payment Model (APM) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA).
There will be two provider types allowed to initiate episodes under BPCI Advanced: physician group practices (PGPs) and acute care hospitals. These provider types can also be the designated risk-taking entity (to be known as a Non-Convener Participant). The model retains the concept of a non-episode initiating third party also being the designated risk taker from CMS (previously known as an Awardee Convener). This could include other Medicare provider types or a non-provider entity, if they could demonstrate the ability to manage risk and coordinate care.
If PGPs and hospitals in a given market both go after the same clinical episodes, CMS has an established pecking order which states that PGPs will have the episode attributed to them. This continues current policy and reflects the need to incentivize physician participation in Advanced APMs. The new model also has a pecking order for how BPCI Advanced will relate to other Alternative Payment Models such as Next Generation ACOs (which trump BPCI Advanced) and lower risk track Medicare Shared Savings Program ACOs (which do not).
Since BPCI Advanced will require the assumption of risk over a 90-day episode, there will continue to be a big role for post-acute care. Studies repeatedly show, and our experience with over 100 episode initiating providers under BPCI amply demonstrates, that a strong well-integrated strategy for post-acute care is one of the keys to success under episodic risk. Hospitals and PGPs will need highly competent partners, including those with the capacity to share risk, in order to manage the full 90 days of a patient’s episode. Given the March 12 application deadline to outline risk-sharing partners, those discussions need to begin immediately.
The new voluntary program has up to 32 different clinical episodes, including 3 episodes that would be triggered by outpatient care in addition to 29 episodes triggered by inpatient hospitalization (as in the current program). BPCI Advanced will now directly incorporate up to seven quality metrics into the target price reconciliation process, similar to how quality is incorporated in the Comprehensive Care for Joint Replacement model. Two of the seven quality measures, all-cause rehospitalization and advance care planning, will be applied across the board, while the others are applied to specific clinical episodes. CMS may add or refine quality measures over time, and they are expecting applicants to have a solid game plan on monitoring quality.
The RFA makes it clear that there will be a selection process for participation in BPCI Advanced. CMS spells out their applicant approval guidelines, but there is no set scoring criteria identified. A review of the guidelines makes clear that CMS is seeking experienced and motivated risk takers, with an ability to redesign and coordinate care. These selection criteria appear to be a reaction to the current BPCI experience wherein many providers put their toe in the water, or were convened by third parties with little support and onerous financial terms, and then quickly dropped out of BPCI. It appears that CMS does not necessarily want to replicate those aspects of the current program.
Health Dimensions Group’s experience in BPCI was with providers taking their own risk (we call it “self-convening”). This model led to much more commitment to the program and sustainable success. We urge providers to give careful consideration to strongly integrated models, with risk sharing to include post-acute care under a Model 3-like aligned payment structure. We can help hospitals, physician group practices, and post-acute providers work out aligned payment and quality structures for maximum success.
In the meantime, all interested providers need to get a seat at the BPCI Advanced design table—March 12 will be here before you know it. Even if you are not a partner with a BPCI risk taker, you will need to know who is going under risk in your market and what you need to do to be a preferred provider. Find out more on the BPCI Advanced web site.
Health Dimensions Group will hold a brief webinar on January 17, 2018, to walk through this new opportunity, as well as provide informational materials. To register for our webinar, “BPCI Advanced: What It Means for Health Systems, Physicians, and Post-Acute,” please click here.
Brian Ellsworth, MA, Director, Payment Transformation
Health Dimensions Group