CMS provided BPCI Advanced applicants with an unexpected gift in early July when they announced a "no harm, no foul" bailout opportunity for all participants occurring in March 2019. At that point, participants can retroactively terminate participation in any or all BPCI Advanced episodes, with no financial risk. This gives participants an additional eight months past the August 1 application deadline to evaluate opportunities in various selected episodes. Unfortunately, it won't be possible to evaluate the financial results of these episodes by March, since many 90 day episodes will not have ended and had their claims paid by that date. However, participants’ efforts at redirecting patients to different postacute settings or at reducing readmissions may be discernible from the data available at that time. This additional time will also give participants the opportunity to create clinical buy-in and start building care management processes, and to evaluate the success of those initiatives. At the March decision point, therefore, opportunities for participation in various episodes may be clearer than those opportunities are now.
Therefore, the reasonable strategy for participation is to apply for any episodes in which success appears possible, and to continue to evaluate those episodes over the next eight months. Here are some guidelines and criteria to use in deciding which episodes should be submitted for participation in August. These criteria follow the episode selection process described in this Singletrack Analytics blog article.
Clinical buy-in: Few bundled payment initiatives succeed without significant involvement from physicians and other clinicians involved in the care of those patients. A high level of involvement would be indicated by previous participation in those episodes in BPCI, identification of a physician champion in the related clinical area, or other clinically led initiatives. A low level of involvement would be indicated by having no communication with physician and clinical leaders in those areas.
Episode volume: Sufficient episode volume is necessary to provide statistical and financial stability over time, to create sufficient financial return on savings to cover the cost of care management, and to simply provide enough episodes to raise sufficient interest in the tasks necessary for success. High episodes volume would be indicated by having more than 100 episodes per year; low episode volume would be indicated by having fewer episodes.
Actionability: High “actionability” is indicated when the cost structure of an episode is primarily composed of services occurring in the postacute period that can be managed by restructuring care. Low actionability is indicated by high index admission and physician costs, whose cost cannot be reduced. In the graph to the left, cardiac valve shows low actionability while congestive heart failure (having a significant portion cause occurring in the postacute period) has high actionability.
Opportunity for combination with other episodes: As we discussed in this Singletrack Analytics blog article, some episodes having low volume or actionability may still create an opportunity for participation in combination with other clinically similar episodes. It may be useful to initially participate in these episodes to see if the potential synergy among the combined episodes occurs.
Advantageous target: Occasionally an episode target is sufficiently high that financial success in that episode may occur even without significant clinical involvement. That effect is shown in the table below for one hospital whose efficiency, PCMA and PAT factors combine for a target in the cervical spinal fusion episode that will be significantly higher than the baseline cost. In this case, it may be financially advantageous to participate in this episode even if no clinical opportunity is apparent. For some fortunate hospitals, these anomalies occurred in high-volume episodes, meaning that a "target play" in these episodes is potentially lucrative. Analyzing targets is discussed in detail in this Singletrack Analytics blog article.
Alignment with other CMS initiatives: As noted in this Singletrack Analytics blog article some BPCI Advanced episodes align with the clinical areas in the CMS Hospital Readmission reduction Program, which means that there may be an opportunity to leverage readmission reduction efforts in those areas. While this opportunity doesn't override those described above, it may provide an additional incentive to include AMI, CHF, simple pneumonia and COPD episodes in the the participation list.
Episode Selection Decision Process
The decision points discussed above are detailed in the flowchart below. While none of the guidelines described above are absolute, following the process shown below may be useful in categorizing episodes for participation. Episodes having "low" values for many of the criteria above may not be worthwhile candidates for participation in August, but it may be worthwhile participating in those having higher values until the final commitment occurs in March.