Most applicants in the Medicare BPCI Advanced program are evaluating participation in various episodes with the goal of achieving financial success by reducing costs in those episodes. Some innovative hospitals, however, are applying an additional criterion for participation in some episodes. Those hospitals are participating in certain episode families in order to obtain data that's helpful to avoid readmissions that would create penalties under the Medicare Hospital Readmissions Reduction Program (HRRP). Under that program, Medicare payments for all discharges are reduced by percentage that is based on the number of 30-day readmissions in six clinical categories: heart attack, heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), elective hip or knee replacement, and coronary artery bypass graft (CABG). But the lack of commonly-available detailed readmission data impedes readmission reduction efforts, particularly if those readmissions occur at a different institution. Without consistent and analyzable source of readmission data, readmission reduction efforts are often unsuccessful.
Using BPCI-A Data to Reduce HRRP Penalties
One of the advantages of participation in Medicare bundled payment programs is the rich and frequent claim-level data provided to participants, including detail on readmissions. Using this data, hospitals can identify the timing, clinical condition, and other factors related to readmissions as well as the surrounding care received by patients who were readmitted. Readmission data for each episode can be reviewed to determine, for example, whether the readmitted patient was a SNF resident at the time of readmission or whether the patient had physician follow-up after discharge. Patients can be individually identified from this data, which allows referencing their hospital EHR data to provide additional information into their care. Statistics can be developed showing rates of readmissions for often-preventable diagnoses such as infections or surgical revisions. And the monthly data provides the ability to design readmission-management processes and review their effectiveness at a later date.
Readmission Reduction in BPCI Advanced Consistent with HRRP
Another factor in considering participating in the HRRP-aligned episodes is that most of these episodes have a significant readmission component of the total episode cost, as shown in the graph below. While readmission cost is a small part of CABG and major joint replacement episodes, it is a significant component of the cost of AMI, COPD, CHF and pneumonia episodes. Therefore, success in these four episodes will require reduction in the same types of readmissions that will also reduce the HRRP penalties. Participation in major joint replacement and CABG episodes may not be appropriate because of the low readmission rate in these episodes, and because they may offer lower overall opportunities for cost reduction. But success in reduction of readmissions in these episodes achieves the dual purpose of creating financial success in BPCI Advanced as well as reducing the HRRP penalties applied to all Medicare payment.
Combining Episodes in BPCI Advanced
Five of the six HRRP-related BPCI Advanced episodes align into two clinically related groups (cardiology and pulmonology), which makes them strong candidates for consideration as a “super-bundle” as described in this Singletrack Analytics blog article. While the low volume of AMI episodes may preclude participation in this episode alone, combining it with CHF and other cardiac episodes such as arrhythmia may create a larger financial opportunity to leverage care management and other resources to create lower-cost. Similarly, combining simple pneumonia and COPD episodes may allow the same resource synergy.