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Playing the Long Game: Why Northwestern Is Participating in Joint Replacement in BPCI Advanced Despite Projected Losses

Jessica Walradt manages Northwestern Medicine’s government value-based care portfolio, which includes BPCI Advanced, the Medicare Shared Savings Program, the Oncology Care Model, and components of the Quality Payment Program. Prior to this, she led the Association of American Medical Colleges' policy, advocacy, and data analytic efforts surrounding alternative payment models. She directly supported approximately 60 hospitals’ and provider groups’ efforts to implement Medicare bundled payment programs. Jessica holds an MS in Health Policy and Management from the Harvard School of Public Health and a BA in Political Science from the University of Richmond.
This article was cowritten with Hannah Alphs Jackson, MD, MHSA, director of managed care at Northwestern Medicine; Brian Walsh, vice president of managed care at Northwestern Medicine; and David Manning, MD, vice chair of the Department of Orthopaedic Surgery and associate professor of orthopaedic surgery at Northwestern Medicine.

On October 1, 2018, the Center for Medicare and Medicaid Innovation (CMMI) launched the next iteration of Bundled Payments for Care Improvement (BPCI), BPCI Advanced. Under this program, participants may select between 1 and 32 clinical episodes for which to accept financial risk, meaning they are accountable for the care and associated healthcare expenditures beneficiaries receive across a 90-day post-discharge period. If Medicare payments for services provided to beneficiaries during this time exceed a target price, the participant must pay back the difference to Medicare.

Meanwhile, if payments fall below the target price, participants are eligible to receive the difference as savings. Northwestern Medicine (NM) is participating in BPCI Advanced with the major joint replacement of the lower extremity (MJRLE) episode. It is doing so despite the fact that it is projected to sustain a loss in this episode based on the current data made available to it by CMMI. This article explains NM’s decision and strategy for participation, as well as thoughts regarding the long-term sustainability of bundled payment programs.

Like many healthcare organizations, NM chose to enter its first Medicare bundled payment program with the MJRLE episode. Relative to other conditions, such as simple pneumonia, MJRLE is often viewed as comparatively easier to operationalize in a bundled payment model due to the relatively low variation in patient acuity, the mostly elective nature of the procedure, which lends to easier patient identification, easily identifiable efficiency opportunities, and ease of mapping out optimal care pathways from before the procedure to well after the procedure.

NM entered the original BPCI in 2015 and successfully executed a multidisciplinary, pre- and postoperative clinical pathway across the clinical care continuum with high provider adherence rates for MJRLE patients. Early in the program, performance was uneven, and it even experience a few quarters of losses, but its financial performance improved and became more consistent as it executed and refined interventions. To date, NM has averaged 4% quarterly savings rate in BPCI MJRLE episodes.

Despite this fact, when NM received its preliminary BPCI Advanced target prices, it found itself in an unfortunately similar position as many other health systems with previous success in BPCI MJRLE or the mandatory Comprehensive Care for Joint Replacement (CCJR) program. When NM compared average episode payments from the most recent full year of BPCI Advanced baseline data (Q4 2015–Q3 2016) with the 2018 preliminary target prices, NM was projected to lose approximately 9% over the course of a year.

Why Is Northwestern Medicine Projected to Lose Money?
How is it that NM could generate average savings of 4% in one program, but be projected to lose 9% in another program for the same 90-day MJRLE episode? The answer comes down to the target price methodology. Under the original BPCI program, participants’ target prices were based on their own historical average episode payments. The methodology utilized for BPCI Advanced is much more complex. Instead of focusing on a provider’s own historical experience alone, BPCI Advanced utilizes national data with regional and provider-specific adjustments. Rather than a simple historical average, BPCI Advanced utilizes 2 compound log normal models to estimate the impact of various patient and provider-level factors on episode spending. These models generate parameter estimates, which are ultimately used to calculate the three major components of the target price calculation (Figure 1). Together, the components generate a target price that is adjusted for patient case mix and the hospital’s historical efficiency and trended forward based on the episode utilization of like providers in a regional peer comparison group. Albeit complex, CMMI is to be applauded for developing the most sophisticated and comprehensive risk adjustment methodology featured in a Medicare bundled payment model to date. The modification also appropriately acknowledges the need to move beyond purely historical averages, as over time efficient providers would be disincentivized to participate.

So, back to the original question: what about this methodology makes it more difficult for NM to achieve savings in the MJRLE episode? One of the main drivers is the peer adjusted trend (PAT) factor, which is based on the utilization of like providers in a census region. NM’s MJRLE episode has a PAT factor of less than 0.90, which essentially means that the utilization and corresponding expenditures for the MJRLE episodes initiated by providers in NM’s peer comparison group were lower than what CMMI predicted. In other words, like NM, providers in this peer group have already become more efficient at delivering care to patients receiving MJRLEs. Additionally, the PAT factor effect is likely to compound over time as providers continue to pursue efficiencies in the MJRLE care pathway, and the resultant target price will continue to decline. Similar arguments can be made for the standardized baseline spending (SBS) figure, which will decline based on an individual provider’s progress.

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