BPCI-A: Lessons Learned from Cohort 1
Thursday, April 25, 2019 | Ginger Biesbrock
Bundled Payment Care Initiative-Advanced launched in October 2018. MedAxiom had several members that took the plunge into this program in several different CV bundles including PCI, AMI, HF, Arrhythmia, Pacemaker and CABG. Now that CMS has opened the application period for Cohort 2, there are lessons to be learned from those that have come before us. During the MedAxiom Spring CV Transforum meeting, several of the programs came together to answer questions and provide insights on successes and challenges. I thought it valuable to provide a recap.
For a brief review, BPCI-A is a CMS-sponsored bundle payment program where Medicare, based on historical spending, risk adjustment, organizational characteristics, assigns a target price to a 90-day episode of care that starts with a trigger event – either a procedure or a hospitalization. The CPT code of the procedure or DRG of the hospitalization triggers the episode. The utilization costs for the following 90 days are tracked; if the costs are under the target price the episode owner is allowed to share in the savings, and if the costs are higher there is a penalty assigned.
The initial cohort had the option at the end of February to drop bundles or even the entire program if they were not performing favorably. The good news is that almost all of the MedAxiom members that signed up stayed in the program, although most did drop at least one bundle.
The overall consensus from the programs that we have talked to have been favorable. However, all noted key lessons that they have learned through the experience.
- Data – one of the most valuable aspects of BPCI-A is that this is the first time many healthcare organizations have access to patient level utilization data throughout an entire episode of care. When a program signs up to be part of BPCI-A, they will receive historical cost to Medicare (utilization) data for their fee-for-service Medicare patients, highlighting the utilization areas for both part A and part B Medicare services specific to the CV bundles. In addition, once the healthcare organization commits to the BPCI-A program, monthly utilization data at specific patient level is provided to allow for tracking of the episodes and monitoring costs. Access to this level of data is imperative to understanding costs and care patterns that lead to higher costs and potentially lower quality.
- Utilization of an effective convener – the current BPCI-A program does not require the use of a convener, however one of the benefits of utilization of a convener is the processing of the CMS-provided data in a way that is actionable. Many of our members have partnered with Archway Health. Archway provides one of the industry’s best comprehensive data analytic tools that allows for review of historical and current data in a way that shows area of risk and opportunity.
- Physician champion – the crux of the BPCI-A program is to drive waste out of the healthcare delivery to CV patients. Requirements to push care to outpatient settings, improve quality outcomes, avoid complications and push patient engagement are extremely important. I can honestly say that I have never seen a program achieve these requirements without strong physician engagement and a passionate physician champion at the helm.
- Defined care plan – each of the BPCI-A CV bundles is triggered by an event, either a procedure such as PCI, device implant, CABG or a hospitalization for Myocardial infarction, heart failure, or arrhythmia. The underlying goal is to drive down unnecessary care variation. The best way to do that is to define the goal of care and best way to deliver that care on the front end. Add to that risk stratification and risk management strategies for the higher risk patients, and the care plan takes shape. The programs that have seen the highest levels of financial success to date have developed patient-specific care plans that allow the care teams to manage these patients proactively, identifying potential risks and alleviating them before they become a reality or cause unnecessary utilization of high cost care.
- Care Manager and patient tracking – most of the healthcare organizations in BPCI-A have identified someone on their team to manage and navigate the care of these patients. Through the use of tracking tools, care plans, and care coordination strategies, this RN-level position becomes the lifeline for these patients throughout the episode. The ideal scenario is that the care manager proactively contacts the patients to follow their progress. In addition, patients need the ability to easily and quickly get ahold of the care manager with questions and concerns.
- 24/7 call support – one of the highest costs of care in any of the 90-day CV bundles is readmissions and ED visits. Insights from Cohort 1 have provided multiple examples of avoided readmissions and ED visits through 24/7 call support. Having a care provider available to answer off hour questions and concerns can often avoid ED visits. Avoiding ED visits typically equates to avoiding readmissions. Same-day appointments and urgent need access were also noted as best practices to avoid hospitalizations.
It is exciting to see best practices emerge as healthcare organizations begin to learn how to better care for their patients throughout an entire episode of care. The game changes significantly when you become financially responsible for care provided beyond the initial procedure or hospitalization. Data is so incredibly important to understand current state and opportunities for care improvement and financial savings. A partner to better understand the costs and targets is imperative. Most invaluable, is a partner that provides as close to real-time feedback as possible with insights into care opportunities. A clinical team that includes a physician champion and dedicated care manager are both identified as important best practices. Finally, access through 24/7 call support and same-day visits is required to avoid expensive ED hospitalizations and readmissions.
We are excited about the next open enrollment period. We know that our entire healthcare industry is moving towards value-based payment programs that require ownership of patients to a degree that we have not had to deal with before. BPCI-A is a great way to ‘dip your toe in the water’ and push to get your program moving in a more comprehensive care direction. The initial enrollment will provide you with historical utilization data to allow for a good understanding of the risk (either positive or negative) for your patients that would fall into the CV bundles. There is no long-term obligation with the initial enrollment. Once you have had an opportunity to review your risk, you then decide which bundles you want to commit to and move forward within the program. I encourage you all to start with getting your data to understand your opportunity, and begin to think about what is needed to be successful. Many of you may already find that you will be successful and with a few tweaks of your care team and clinical model, your long-term success will be ensured. We will be providing you with up-to-date information throughout the open enrollment period. Make sure you don’t miss this important opportunity.
Learn more about the next open enrollment period at medaxiom.com/bpci-advanced and join us at our upcoming webinars:
BPCI Advanced Open Enrollment: What you need to know
Tuesday, April 30, 2019, 1:00 pm
BPCI Advanced: What's New for Cohort 2?
Wednesday, May 8, 2019, 1:00 pm
BPCI Advanced: Insights and Lessons Learned from Cohort 1 CV Participants
Wednesday, May 22, 2019, 1:00 pm
Illustration: Lee Sauer
About the Author
Ginger Biesbrock, PA-C, MPH, MPAS, AACC, is Senior Vice President, MedAxiom Consulting. She is a respected executive, provider and teacher with 20+ years of experience in the health care industry with a concentration in clinical care and operations. Before joining MedAxiom Consulting, Ginger was Director of Operations at West Michigan Heart, a 39 Physician practice with 24 mid-level provider. At West Michigan Heart, Ginger oversaw all operations for ambulatory services, tertiary care and rural health practices. Prior to that Ginger was the COO of the Cardiovascular Group at Centra-Health.
Her areas of consulting expertise include APP Utilization, Care Team Optimization and Transitions of Care.
To contact, email: firstname.lastname@example.org