Positioning for success with bundled payment models

Taking a closer look at an evolving bundled payment model, BPCI Advanced

As part of the healthcare’s industry shift from fee-for-service to value-based reimbursements, the Centers for Medicare & Medicaid Services (CMS) and commercial payers have developed an array of financial models. Healthcare organizations must determine which programs are the best fit for their goals and capabilities, as well as which ones can help them identify gaps and build key competencies. It’s important to periodically re-evaluate these decisions to optimize reimbursement opportunities.

For example, let’s look at Bundled Payments for Care Improvement Advanced (BPCI Advanced). With this voluntary program, CMS intends to improve quality and reduce cost by bundling payments for 37 clinical episodes. The first cohort started participating in BPCI Advanced in October 2018, and CMS opened an application for a second cohort, which will close on June 24, 2019. CMS plans to make longitudinal data available in September to help organizations understand performance and savings potential, with a target of finalizing participation agreements in the fall and a start date of January 1, 20201.

For resource-constrained healthcare providers, participating in any new program can feel like adding one more responsibility to a list that is already too long. But there are advantages to participating that are worth a second look.

A program like BPCI Advanced is an opportunity to strengthen alignment and meaningful engagement –especially with specialists and potentially post-acute providers. Because BPCI Advanced qualifies as an Advanced Payment model, specialists have the opportunity to receive a five percent increase in CMS reimbursement and access to gainsharing incentives that align with the goals of the program.

Participants in the program will have access to rich and robust data, and making use of that information can provide clarity, control and confidence in managing episodes of care. And right now it’s voluntary, which fosters the opportunity for a learning path for participants to select episodes with the optimal mix of financial gains that align with organizational priorities before CMS rolls out additional mandatory bundles in the future.

With BPCI Advanced, as with any bundled payment model, there are three steps participants can take to improve their chances of success:

1) Right-size risk – With BPCI Advanced, participants can scale the opportunity to be as large or small as clinically makes sense. For any bundle model, providers should evaluate the data to determine which episodes are likely to generate financial wins, dial in their desired level of risk and select only what clinically and strategically fits with what they are already doing.
2) Drive performance – Providers can potentially mitigate risk with actionable clinical and financial insights around episode performance. They can identify what specific levers to pull and adjust as needed to improve performance for BPCI Advanced and other related programs such as Medicare Shared Savings and Medicare Value Based Purchasing, as well as models that are being brought forth by commercial payers.
3) Improve quality and care – BPCI Advanced and other value-based payment models share the same mission: to optimize patient experience, reduce cost and improve outcomes. Remaining focused on these goals aligns participants and payers and can be a part of a provider’s growing value-based-care portfolio.

Be prepared to act quickly to meet the CMS application enrollment deadline of June 24. If you’d like more information about BPCI Advanced, you can view a recent webinar.

Contact us to find out how IBM Watson Health can to help you along your value-based care journey, whether with BPCI Advanced or another model, with data and analytics

  1. Description of CMS plans as described on website, June 3, 2019 https://innovation.cms.gov/initiatives/bpci-advanced