New data from the Centers for Medicare & Medicaid Services (CMS) shows that about 16 percent of participants have dropped out of the agency’s Bundled Payments for Care Improvement—Advanced (BPCI Advanced) model.
Last October, CMS announced that it signed BPCI Advanced agreements with nearly 1,300 hospitals and physician group practices. The participating entities receive bundled payments for certain episodes of care as an alternative to fee-for-service payments that reward only the volume of care delivered.
For some background, in January 2018, CMS announced the launch of the voluntary BPCI Advanced model, noting that it “builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and towards paying for value.” CMS Administrator Seema Verma stated last fall in the announcement of the model’s participants that “To accelerate the value-based transformation of America’s healthcare system, we must offer a range of new payment models so providers can choose the approach that works best for them.”
The BPCI Advanced model qualifies as an Advanced Alternative Payment Model (Advanced APM) under MACRA, so participating providers can be exempted from the reporting requirements associated with the Merit-Based Incentive Payment System (MIPS) and potentially qualifying them for incentive payments
BPCI Advanced initially includes 32 bundled clinical episodes—29 inpatient and three outpatient. Currently, the top three clinical episodes selected by participants are: major joint replacement of the lower extremity, congestive heart failure, and sepsis, according to CMS.
But CMS permitted participants to withdraw from the program by March 1 without facing any financial risk. The agency just released new data showing that after the deadline, 1,086 participants remain for year two of the model. The number of participants remains “robust,” CMS said.
Remarking on the number of participants that have dropped, Gina Bruno, vice president of clinical strategy at naviHealth, a Tennessee-based post-acute care management company that works with BPCI participants, wrote in an email to Healthcare Innovation that she is “not surprised to see episode initiators withdraw. However, many participants remained in the model, even with this opportunity.” She adds, “While naviHealth withdrew some episode initiators and clinical episodes, all of our health system partners continued broad participation. That’s because we applied the same methodological approach to episode selection and clinical operations that we would have if there was no such withdrawal opportunity. Overall, we’re encouraged there's still a large cohort of participants because it shows their commitment to value-based care, even if the process is challenging.”
In contrast to the traditional fee-for-service payment system, in this new episode payment model, participants can earn an additional payment if all expenditures for a beneficiary’s episode of care are less than a spending target, which factors in measures of quality. Conversely, if the expenditures exceed the target price, the participant must repay money to Medicare. The original BPCI initiative ended on September 30, and BPCI Advanced picked up where it left off, starting on October 1, and running through the end of 2023.
Meanwhile, Keely Macmillan, general manager of BPCI Advanced at Archway, another organization that works with specialty providers to build bundled payment programs, notes in an emailed response that “The numbers tell an interesting story for orthopedic providers. We’re worried that many of the orthopedic groups that stayed in major joint replacement of the lower extremity (MJRLE) will have significant negative reconciliations in October. We’re surprised more didn’t drop, and our guess is that it’s because they have little visibility into their data and performance.”
Importantly, in 2017, CMS finalized a rule that cancelled mandatory hip fracture and cardiac bundled payment models. Verma has said in the past that she doesn’t think bundled payment models should be mandatory, a sentiment that some industry experts wholeheartedly agree with. But more recently, Health and Human Services (HHS) Secretary Alex Azar did hint that the government is planning new mandatory bundled payment models in the future.
As such, according to Macmillan, it’s important for providers to know that it is “now or never to consider participating; at the very least, submit an application, get your data and evaluate your opportunity risk-free. This may be their last voluntary chance. Seema Verma announced late last year CMS plans to roll out mandatory bundles soon.”
Meanwhile, for new potential participants, Bruno says she would “encourage applicants to think critically about episode selection and readiness for care redesign, so they take on enough episode volume to effectuate change within their hospitals or practices. CMS does not intend to offer another enrollment opportunity, so time is running out for new applicants to make a decision on participation.”