On March 1, providers participating in BPCI Advanced had the option of dropping bundles or dropping out of the program entirely. The Centers for Medicare & Medicaid Services (CMS) provided this option to the more than 1,500 providers that began the program in October 2018, creating an effective “trial period” in this voluntary model.
Now, more than 1,200 providers remain in the program. Additionally, CMS announced that it will open a new window for a second cohort of providers to join at the beginning of 2020. After six months of early results, there are some observations and lessons we’ve gathered that should be useful to new providers considering the program.
1. The drop deadline made the program more attractive
With BPCI Advanced, the March 1 drop option changed the participation calculus last summer. More providers committed to the program and went live in October, that otherwise wouldn’t have. Many providers chose bundles they wouldn’t have. The safety net that the drop option provided allowed participants to get more data, build infrastructure, experiment with new clinical processes, and more. Some providers succeeded and stayed in with the drop option, while many ended up dropping out of the program entirely or dropping some bundles.
Making decisions on only a few months’ worth of data requires the ability to use the data to quickly assess and adjust performance. We encourage providers continuing in the program and those considering joining in Cohort 2 to ensure that they have the tools necessary to make informed, data-driven decisions throughout the rest of their program.
2. Data from CMS was robust and helpful
A benefit of participating in CMS bundled payment programs is the access to performance data that participants receive. While receipt of the BPCI Advanced data from CMS took longer than we had hoped, it was helpful in assessing risk and early performance for our partners in the program. In Cohort 1, CMS produced target pricing summary workbooks that provided rich intelligence, including patient-level Hierarchical Code Conditions (HCCs) and other risk factors that allowed participants to calculate patient-specific target prices and likelihood of loss.
3. Participation in the program has led to real improvements in patient care
While many providers think of bundled payment programs for their ability to reduce care costs, improvement of care quality is equally important. And they’re working: In just the initial six-month performance period of BPCI Advanced, providers have expressed that they are much more aware of how their patients are doing after a procedure or acute exacerbation. Additionally, providers say they have a much better understanding of what drives variation in care, costs, and outcomes across all types of providers and within their own organizations. We have also seen more continuity of care between inpatient care and post-discharge care. Bundled payments require continuous monitoring and adjustment, and as a result, they promote more attention to holistic care planning.
4. Trends in orthopedic and cardiac bundles
In our years participating in bundled payment programs, we have found that bundles involving orthopedic procedures have done particularly well, which has also been confirmed by various studies. Cardiology bundles have also emerged as attractive bundles in BPCI Advanced. For these reasons, we have paid particular attention to these specialties in the post-dropout data.
About 35% of episode initiators who had been participating in Major Joint Replacement of the Lower Extremity (MJRLE) dropped the bundle. Given the challenging pricing model for MJRLE bundles, we’re surprised that even more orthopedic providers didn’t drop this bundle. There is some concern that there will be significant negative MJRLE reconciliations across the program in October.
As expected, orthopedic practices had a decline in MJRLE volume as a result of total knee replacements being reimbursed as hospital outpatient visits, which were not an eligible outpatient bundle in Cohort 1.
To adjust for these volume issues, CMS confirmed that total knee arthroplasty (TKA) will be an eligible bundle in Cohort 2.
In spinal procedures:
Bundles with the highest drop rates include Combined Anterior-Posterior Spinal Fusion, with 60% of episode initiators dropping the bundle.
In the fiscal year 2018, CMS added more than 100 ICD-10 procedure codes to the Combined Anterior-Posterior Spinal Fusion MS-DRGs, creating a shift in attribution among spine bundles.
Cardiac bundles had the highest retention rate of any category.
Within the category, cardiac arrhythmia had the highest retention rate, with 71% of episode initiators continuing to stay in the bundle, followed by CHF with 69%, and heart attacks (AMI) and chronic obstructive pulmonary disease (COPD) both with 67%.
5. More sophisticated bundle definitions are needed
In addition to the new outpatient TKA bundle, CMS may be considering other program adjustments for Cohort 2 of BPCI Advanced. After looking at the data, we’ve developed a set of recommendations for CMS we think would better align incentives with improved patient care.
More refined trigger codes for bundles. Inpatient bundles are triggered by MS-DRGs, while outpatient bundles are triggered by specific HCPCS codes. CMS should consider using diagnoses codes or procedures codes as trigger events for some bundles.
Outpatient (OP) percutaneous coronary intervention (PCI) needs some readmissions adjustments for valve replacements (TAVRs).Among providers working with Archway participating in PCI, a common barrier to achieving overall savings in this bundle was the small number of very expensive TAVRs, which are counted as readmissions following the anchor OP PCI procedure.
Our outpatient PCI providers that decided to drop that bundle on March 1, 2019, suffered estimated average losses of $2,100 per episode, driven by a very small percentage of cases that had planned TAVRs that were clinically appropriate.
Our analysis within and among cardiology groups showed variation in the protocols used for deciding when to stage PCI before TAVR procedures. We suggest that cardiology identify and establish best practices. However, even with the implementation of standardized best practices, there will continue to be patients for whom the most appropriate treatment is a PCI before a TAVR. This indicates a need for CMS to apply more acute specifications for the OP PCI bundle so as to not create incentives for compromising patient safety.
Currently, CMS includes both cardiac valve procedures and endovascular cardiac valve replacements as trigger events in the Cardiac Valve bundle. Given the disparity in costs between the two types of procedures, we recommend CMS split them into two separate bundles: Cardiac Valve and TAVR.
Spine bundles need to be re-configured. There are nearly 2,000 ICD-10 procedure codes that map to the five spine bundles included in Cohort 1, and many of these procedures can map to more than one spine bundle. CMS should re-configure how each spine bundle is defined. Additionally, more outpatient bundles could make the program more attractive to spine providers. Cervical spinal fusion would be a particularly good addition. Many patients are discharged the day following their procedure, and these cases are paid under the Outpatient Prospective Payment System (OPPS), which will not currently trigger a cervical spinal fusion bundle.
One of our biggest takeaways from the early months of BPCI Advanced is that experience is not required to drive success— providers with and without prior experience in value-based care have both been successful.
The next open window will begin in mid-April 2019, and it will be the last; CMS reiterated that it does not plan to re-open the application window a third time. After this, mandatory bundles will likely be the way of the future. CMS Administrator Seema Verma announced in late 2018 that the agency plans to roll out mandatory bundles, including for radiation-oncology, and cardiology.
Application to BPCI Cohort 2 will be non-binding, as was Cohort 1. Providers considering the program should apply to get their data and evaluate the program risk-free. Value-based care continues to be the direction in which the industry is moving, and providers can either raise their hands to participate now or wait to be dragged along when the time comes.
If you’re considering joining BPCI Advanced, analyze your opportunity first with a BPCI Advanced Scorecard.