Q&A: What do providers need to know about BPCI Advanced?

Since CMS announced its new Bundled Payments for Care Improvement (BPCI) Advanced Model on Jan. 9, healthcare providers have been trying to figure out whether the program is right for them.

On one hand, it gives health systems a chance to earn a 5 percent bonus through the Advanced Alternative Payment Model (AAPM) track of the Quality Payment Program (QPP). On the other, if a system doesn’t meet benchmarks for high-value care, it will face financial penalties.

With the March 12 application date approaching, Keely Macmillan, the general manager of BPCI Advanced at Archway Health, spoke with Cardiovascular Business about the new program and how it differs from the first BPCI initiative, as well as the opportunities for cardiovascular specialists among the 32 clinical episodes included in the voluntary payment model. Archway Health is a company strictly devoted to helping providers navigate bundled payments.

Here are some highlights of Macmillan’s conversation with CVB, edited for clarity and length:

Cardiovascular Business: From my understanding, health systems can participate in as many or as few episodes of care as they’d like. Does Archway recommend hospitals new to this get their feet wet with a limited number of these, or do you think it’s a good idea to dive into more full participation right away?

Keely Macmillan: Frankly, it depends. As part of the application process, there’s a nonbinding application that is due March 12. As part of submitting this nonbinding application, you can get your data and your target prices and evaluate your full opportunity in the program. And then you’re exactly right—you can pick and choose whatever bundles you want to participate in and that can be as few or as many as you might want for the October 1 start date.

You certainly want to make informed decisions about which bundles to participate in, and you’re not going to be able to evaluate all the opportunities and the risks unless you get your data from CMS.

We’re all creatures of habit and change is difficult to implement, even when it might be helpful in the long run. How do you convince people that participating in these bundled payment models is worthwhile—even when they’re still voluntary?

That’s a fair question. First, we would point to the success of the first program. We have a lot of provider partners who are participating in the current BPCI, or the 1.0 program, who have had a lot of success. One, there’s a lot of upside revenue. Medicare margins are notoriously tight, and this is an opportunity to earn new Medicare revenue on top of your normal Part B fee-for-service billing.

And two, with the normal fee-for service reimbursement system, CMS doesn’t really give you any incentive or the tools or information necessary to really succeed in these programs whereas with BPCI Advanced, CMS is going to give you all this rich intelligence that’s going to help you identify the path to improvement and where the … high-opportunity areas are, and they’ll give you this advanced lead-up time to evaluate your data to identify what makes sense. It’s worth looking at it.

Obviously, there’s financial risk involved but it sounds like your recommendation would be that the way to mitigate that is at the start by analyzing data and deciding where to move forward. Are there other ways systems can mitigate potential risk?

That’s a great question, and yes, there is financial risk. With opportunity analysis and strategic bundle selection, you can mitigate a lot of that risk. You can look at your target prices and look at your historical data and look at how you compare to many benchmarks and decide which bundles really make sense to participate in.

CMS does offer risk protection in its program. They offer a 20 percent stop-loss at the episode initiator level, so they do offer some risk protection and then there is also some risk protection at the individual bundle level in that they sort of trim the outlier expenditures to provide some additional protection.

And one of the biggest differences between BPCI Advanced and the original program is that they’ve really made the target pricing more sophisticated such that it risk-adjusts for your actual patient population. So, they’ll actually true up your target prices based on your patient population, so that provides another layer of risk (protection) in that if the patients that you see during the performance period are sicker than had been reflected in your preliminary target price, CMS will adjust accordingly.

Are there any challenges or benefits with BPCI Advanced specific to cardiovascular care or is it similar across specialties?

Cardiac care represents roughly half of all the bundles included so there’s a tremendous amount of opportunity here for cardiology in general. They added three new outpatient bundles and two of them are cardiovascular—that’s outpatient PCI and outpatient cardiac defibrillator.

Until now, the only opportunities for physicians to qualify for that Advanced APM track under MACRA were ACOs (accountable care organizations), which were largely geared toward primary physicians. This is really the first opportunity for cardiologists and many specialists to qualify and get this 5 percent bonus under MACRA, so that’s an additional reason or incentive for cardiovascular specialists to evaluate this program.

How will day-to-day responsibilities change for specialists and administrators in terms or reporting and monitoring where they are in this program?

In the first two years of the program, the quality measures are all going to be claims-based. There won’t be any additional quality reporting requirements.

As far as tracking patients, there will have to be a change in behavior. Right now, there’s no incentive nor are there tools for providers to track their patients 90 days after a cardiac exacerbation, and this program provides incentive as well as the insight to do so.

The initial application deadline is March 12. Are there any other benchmarks or dates that people need to have in mind?

In May of this year, you receive all your data from CMS so this is claims data, not just for you, but for all of the providers who treat your patient population, as well as your quality data and your target pricing. So, May is another big deadline in that it’s when providers receive all of this insight and can start to go through it and understand what their opportunity is.

It’s not until August that providers need to commit and decide whether to start participating in BPCI Advanced. And when I say commit, you start the program October 1 but you can drop out January 1 of 2020. So, you are committing to 15 months of program participation but you can drop out in January of 2020, or you can drop certain bundles and add certain bundles in January 2020.

Do you expect these models to eventually become mandatory and, if so, how soon?

I think they’re going to spend years gathering insight from these trial or voluntary programs that are only limited to certain providers … and see what they can learn from them to develop policies that are more applicable to a broader audience of providers. I think it would take years for them to evaluate real results of these programs, but I would expect them to incorporate success stories from these models into mandatory reimbursement.