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Hospitals and physician groups take on risk in BPCI Advanced model

Voluntary bundled payment model is tied to performance and also qualifies as an APM for MACRA.

Susan Morse, Managing Editor

Hospitals and physician groups launched into the new Bundled Payments for Care Improvement Advanced on Monday, though the new model wasn't the flip-of-a-switch that defined another October 1 start date when providers began using new ICD-10 codes in 2015.

"It's not this big ceremonious tape cutting, it just sort of starts," said Chris Garcia, CEO of Remedy Partners, a convener for participants.

There's been a huge surge of interest in the advanced bundled payment model as compared to the former "BPCI classic."

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"We've been in that program now five years. We've seen a tremendous uptick in interest," said Harrison Frist, national president of Operations for naviHealth.

"We ended up tripling our program from BPCI classic," Garcia said.  "About 95 percent continued to advanced. Of those, they took a more robust involvement and expanded the program size by taking on more bundles."


In BPCI Advanced, providers can choose from 32 clinical episodes. Of these, 29 are inpatient and three, outpatient. Payments are based on performance during a 90-day episode of care and continues after discharge or the outpatient procedure.

Medicare gives participants the full claims file through the episode of care.

Remedy began keeping track of patients who showed up for care on Monday and who were admitted to a hospital. Through  a technology-supported workflow, Remedy keeps track of provider engagement with the patients.

For instance, after discharge, the general statistic is that a third of patients go to a skilled nursing facility or inpatient rehab, a third go home with home care and a third go home alone.

At the time of discharge, Remedy's decision support tool triggers a series of questions for caregivers. If the patient is sent to a SNF, the question is, what prevented that person from being sent home with care, a less expensive alternative that is usually more desirable for patients.

Under the bundled payment program, providers call home service companies, or give patient a list of home services. Also, some home health companies come in to the hospital and do an assessment before the patient is discharged, Garcia said.

"That's best practice," he said. "A better outcome is to go home and stay at home and not get readmitted to the hospital."

Remedy can help providers make connections to social services such as the local Meals on Wheels.

"Patients really are benefitting from this program," Garcia said. "We're doing a more thoughtful job. There's a financial incentive in place to do that."

Navihealth deploys care teams in the hospital as well as in post-acute care facilities after having involved the entire health system from the CEO, CFO, and chief clinical officer.

"We're here to manage the patient longitudinally, not just with a care team but from post-acute to home," Frist said. "That brings to life how bundled payments are leveraged."

Navihealth, as do most conveners, shares in the financial risk, both upside and downside.


CMS has made it clear that it wants providers in current and in future payment models to take on more financial risk. In August, CMS announced an overhaul to the safer Medicare Shared Savings Program by limiting upside-only risk to two years, from six.


August 8 was the deadline for organizations to decide whether to  participate in the bundled payment model. The performance period runs through December 31, 2023. CMS is providing a second application opportunity in 2020.

Providers can reassess their decision in March, but Garcia and Frist said all who signed have made a multi-year investment, and commitment, to the model.

Some may drop a bundle if it's not performing the way they had expected, Garcia said.

"All of our customers are committed to going forward," Garcia said.
"You do have to make a fairly significant investment to stay in."

Frist said, "We have not seen a lot of systems look at the March date as a backstop."

Systems are committed to managing patients differently, Harrison said. It's not just about investing in infrastructure, but in change management.


Three of the main reasons for participation in this go-round are that providers are more prepared to take on the model, it comes with the incentive of qualifying as an advanced alternative payment model and its 5 percent bonus under MACRA, and, if they had any doubt, healthcare systems have more reason to believe that CMS is serious about moving to value-based care.

"I think the bigger rationale in participating, more so now than five years ago," Frist said, "there's more clarity that we're moving in a direction of value-based care probably quicker than they realized three-to-five years ago."

Another reason, said experts, is that it has become clear that bundled payments work whether that's judged by cost or patient experience.

Twitter: @SusanJMorse
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