Build, Buy, or Both: Tips for Directly Contracting with CMS in BPCI Advanced

Why Build Your Own?  

With the next and final enrollment opportunity to join the voluntary BPCI Advanced program to open soon, healthcare organizations must consider not only if they will participate, but also how they will participate. More health systems and physician practices joined the first cohort of BPCI Advanced as episode initiators, and directly contracted with CMS rather than going through a convener. We see this shift as a vote of confidence from providers, both in themselves and in bundled payments.  

CMS has encouraged providers to make this shift and take greater ownership of their bundled payment programs. The agency has said it wants 100% of its providers in both upside and downside risk arrangements by 2025. To make two-sided risk more attractive in BPCI Advanced, in 2018 CMS added a 20% stop-loss provision at the episode initiator level, limiting the amount of downside costs providers could owe and making it easier for providers to take and manage risk on their own. 

Entering into a BPCI Advanced agreement directly with CMS, rather than through a convener, allows providers more control over their data and direct contractual connection to CMS. Additionally, it provides more control over key program decisions such as gainsharing structures, funds flow process and timing, reconciliation process, and others. At Archway, we have been working with provider’s who have their own contracts with CMS since 2011, and our experience has revealed some keys to success in this structure. 

Services to Outsource

The success of bundled payment programs lies at the intersection of analytics, technology, program administration, care redesign, patient-tracking and risk management. Some of these activities can be managed directly by providers, and others are more commonly outsourced, even by the largest health systems in the country. 

Core convener activities that are generally outsourced to an experienced management services partner include:

  • Upfront and ongoing program analysis and reporting 

  • Commercial contract bundle definitions, analysis and negotiation 

  • Performance benchmarking and optimization assistance 

  • BPCI program administration and advocacy 

  • Preferred provider analysis and performance monitoring 

  • Gainsharing agreement development 

  • Real-time patient and performance tracking software 

  • Claims adjudication and reconciliation management 

  • Funds distribution 

  • Periodic performance evaluation and coaching 

A third-party expert that is focused on developing and delivering value-based services such as these can generate economies of scale that no practice can develop alone. By offloading some responsibilities, organizations can free up their clinicians and program managers to focus on improving care.

Commonly “In-sourced” Services

Our experience has shown that providers directly contracting with CMS are more comfortable developing and managing the care management and patient engagement components of a bundled payment program. These activities generally include:

  • Care management process design 

  • Care management infrastructure and oversight 

  • Developing and executing agreements with a preferred provider network 

  • Quality monitoring and reporting 

  • Patient-reported outcome collection and reporting

These activities are some of the core drivers of success in bundled payment programs. While we do design and manage these activities for some providers, most organizations ultimately have the internal capabilities and resources to keep these in-house. 

New Considerations for Downside Protection

As providers prepare to take more downside risk while managing their own contracts with CMS, risk management becomes more critical. Providers now have to consider how to finance and protect downside liability, whether on their own balance sheets or through insurance partners or captives. For this reason, stop-loss insurance is gaining popularity among providers. 

Purchasing stop-loss insurance coverage is one way a provider can minimize potential losses while also creating access to additional upside. As the market evolves, we expect to see increasing innovation around insurance solutions for providers, and ultimately an environment in which more providers adopt these strategies.

How Archway Can Help 

We have experience as a traditional convener who holds the contract with CMS, and as a management services partner to provider contracting their own programs with CMS; we’ve been doing both since the early days of the BPCI Classic program. Additionally, we’ve recently partnered with an A-rated insurance carrier to collaborate on a stop-loss program called Value-Based Risk Protection. 

We are a flexible partner that can help design and manage the bundled payment program model that works best for your organization — regardless of who holds the contract with CMS. We can perform any or all of the activities listed above to help create a program that works for them. Our goal is to generate success in all forms of convener relationships and financial arrangements. 

If you’re considering applying to BPCI Advanced, or are already managing your own program, get a demo of our analytics and care management technology, or reach out to our value-based care team for personalized guidance.