Three Operational Issues to Look for in the BPCI Advanced Announcement

Darcie Hurteau has worked in the healthcare industry for more than 15 years. For the last 10 years, Darcie has helped hospitals and other healthcare providers understand changes in Medicare’s reimbursement systems. As Director, she leads the DataGen team that provides decision support and education to hospitals and health systems across the country as they prepare for health reform payment strategies. Darcie started her career in healthcare finance at Albany Medical Center in Albany, New York.
Current and potential Bundled Payment for Care Initiative (BPCI) participants are looking for answers to 3 key operational questions about BPCI Advanced. Here, we discuss what to look for in terms of quality metrics, gainsharing rules, and evaluation and participation periods.

This article has been co-authored by Jonathan Pearce, Principal, Singletrack Analytics.


Many current and potential bundled payment participants are eagerly awaiting the announcement by CMS of the revised Bundled Payment for Care Initiative (BPCI) program. CMS has planned this “BPCI Advanced” program for many months, but announcement of the details has apparently stalled somewhere within the government. This raises concerns for the many current BPCI participants who are hoping to continue
their participation in an ongoing program, as well as the hospitals and physicians who did not participate in BPCI, but may now wish to join the program.
 
The attractiveness of BPCI Advanced will depend on multiple, currently unknown, factors. In an earlier blog post, we weighed in on the program’s most significant programmatic details that we are waiting to see; however, that’s only half of the equation. For healthcare organizations participating in BPCI now—or considering how they can prepare to participate in BPCI Advanced—understanding how BPCI Advanced will
change the operational aspects of the program is critical for strategic planning.
 
Current and potential BPCI participants are looking for answers to 3 key operational questions about BPCI Advanced:
 
How will quality metrics be defined? 

In the current BPCI program, quality metrics are not used to affect financial performance; however, in the Comprehensive Care for Joint Replacement (CJR) program, a participant’s quality scores determine the CMS discount applied to the episode targets. Participants with high quality receive a higher target, while participants with low quality may be denied payment of any surplus that they may have earned. The selection of quality metrics and their applicability to payment will be a significant factor in the BPCI Advanced program.
 
One of the challenges participants in CJR and CMS' Oncology Care Model know well is the data lag on their performance metrics. In the current models, participants receive information based on data that are 3 to 6 months old, which creates a lag in how they adjust performance and workflows, which means they may face penalties without being able to do anything about them. Hopefully, BPCI Advanced will improve on how quality metrics are defined and used—and set up more effective reporting timelines.

What will the gainsharing rules be, and how will they affect current BPCI participants who continue into BPCI Advanced?

In both BPCI and CJR, participating hospitals were allowed to share financial surpluses with physicians and other providers who were directly responsible for creating those surpluses. Where implemented, these gainsharing programs were often highly successful in creating the physician engagement necessary to effect change. Therefore, the presence of gainsharing programs may be a significant factor in the decision of a hospital to participate in BPCI Advanced.
 
With the BPCI program ending in 2018, participants would be faced with the discontinuation of gainsharing programs, the requirement to delete all of the data and derivative products from that program, and the loss of ongoing data. Thus, many participants may wish to continue the activities that they initiated as part of BPCI. The extent to which this is possible will be determined by rules governing gainsharing, data retention, and other aspects of the program. It will be very interesting to see if participants can keep the data and continue in their existing episodes.

What will the evaluation and participation periods be?

In the BPCI program, participants were allowed to receive their historical episode data and evaluate participation options for almost 2 years before being required to commit to participation in certain episodes. Following that, they were allowed an additional year during which they could add or drop episodes; after that date, participants could drop episodes but could no longer add them.
 
In the BPCI Advanced program, participants will need sufficient time to receive their historical episode data, identify current care patterns and costs, and begin to develop participation strategies. Their ability to be flexible in participation, terminating episodes in which they cannot be successful and adding additional episodes, and applying experience in dealing with bundled payments, will be critical to their selection to participate in this program.
 
While the initial term of the BPCI program was to be 3 years, CMS extended it to allow early participants to remain in the program through the second quarter of 2018. The CJR program runs for 5 years.
 
Regardless of how the BPCI Advanced changes play out in practice, it is a fair bet that day-to-day operations for participants will not be the same. Once CMS releases BPCI Advanced, keep a close eye on how these 3 operational questions are addressed. If you missed our last blog on the 3 programmatic questions we will have in mind on release of BCPI Advanced, be sure to take a look here.

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