1. Prepare for financial modeling: In May, you'll receive Target Prices based on your historical volumes (for up to 29 inpatient and 3 outpatient bundles). Depending on what you requested in your Data Request and Attestation, you may also receive aggregate historical claims data and patient-level claims data. Having a clear plan for who will be doing the financial modeling is critically important since you could be exposing yourself to millions in dollars of risk (20% of episodic costs at an organization level can add up quickly).
2. Devise an episode selection strategy:We focus on three key factors when selecting which Episodes to participate in:
- Arbitrage opportunity: CMS' target price methodology rewards providers that have historically been more efficient than their peers and on some bundles you may have a favorable starting position compared to your Target Price (even after factoring in the program’s 3% discount).
- Favorable partnerships: Some of our partner organizations have strong relationships with their cardiologists—others do not. Depending on the quality of service line-level relationships (from both the hospital and physician perspective), you may decide that certain bundles are a good or a bad idea.
- Alignment with strategy: Focused strategies to reduce readmissions and/or post-acute care costs will be critical to success under BPCI Advanced and some bundles will be impacted more than others by these initiatives. For example, Skilled Nursing Facility (SNF) spending can account for more than 20% of costs for Stroke and Urinary Tract Infection episodes. If you have a preferred SNF partner network (or are in the process of building one), you may feel more confident about your ability to reduce SNF spending. Similarly, we've seen that more than 35% of Cellulitis and Congestive Heart Failure episode costs can be driven by readmissions. If your organization is in the process of implementing a heart failure clinic or other initiative focused on reducing readmissions, you may be more inclined to pursue these bundles.
3. Strengthen relationships with post-acute providers: An Institute of Medicine study found that 73% of variation in overall Medicare spending could be explained by variation in post-acute care spending. To be successful under BPCI Advanced, you will need a high value, high performing post-acute network that discharges patients to the right level of care and effectively finds the best provider for the care that is needed. Identifying and partnering with the right post-acute providers is a crucial first step, but ensuring an effective network will rely on your ability to drive utilization of the network and create meaningful working relationships across the continuum.
4. Optimize your EHR around care redesign: While we realize “optimizing your EHR” is a broad recommendation, there are a number of tactical steps we think organizations should take. First, identify care pathways for the Episodes you've selected and make it easy to adhere to best practices at the point of care. Second, build risk-stratification triggers into your EHR so care team members are acutely aware of which patients are at highest risk for readmission or other adverse outcomes. Third, consider building a flag in your EHR to indicate when a patient is within the bundle's 90-day window post-discharge. Finally, make sure you're set up to report on and excel at the program's seven quality measures. While the program's initial quality measures are all claims-based, you may need to work with your EHR vendor or change your documentation workflow to ensure you get full credit for the Care Plan (NQF #0326) and Selection of Prophylactic Antibiotic (NQF #0268) quality measures in particular.
5. Align program with your overall MACRA and physician alignment strategy: If you applied as a hospital episode initiator, you'll be able to include independent physicians on your list of NPRA Sharing Partners and make them eligible for MACRA's 5% APM bonus on all their Medicare fee-for-service revenue. Not only is this a great benefit of being in the BPCI Advanced program, it also serves as a complementary strategy for specialists who often feel left out of ACO programs or primary care-focused programs like CPC+.
6. Create a clear plan for mitigating and sharing risk: During the application, you had to outline existing financial arrangements and your plan for NPRA Sharing—but many organizations kept this at a pretty high level. Part of your success will hinge on figuring out how to appropriately delegate risk and incentivize physicians and post-acute partners. These decisions will impact strategy and success so much that we believe you cannot consider them too early in the process. You may also want to consider reinsurance or stop loss protection at the individual patient level since the program only caps losses at 20% of total episodic costs at the Episode Initiator level (i.e. either a hospital or a physician tax ID). This means that risk will not be capped for each bundle (e.g. Sepsis) and it won't be effectively capped at the individual patient level for extreme outlier cases.
While the Oct. 1 model start date may seem like a long way off, we all know that redesigning care takes time and a lot of hard work. We recommend starting with no-regrets strategies first (e.g. building relationships with post-acute care providers) and then making major investments this summer (e.g. hiring staff, optimizing your EHR) once you've seen your Target Prices and you're sure you'll end up participating in the program. In the meantime, congratulations on completing your application and we hope you'll let us know any questions you have and if we can partner with you around financial modeling, building a post-acute care network, or any of the other recommendations we've outlined above.
This article first appeared in Becker's Hospital Review.
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