CMS Bundled Payment Train Back on Track. Should You Board?

BPCI-A is the Trump Administration’s first offering that qualifies as an advanced alternative payment model (AAPM) under the Quality Payment Program (QPP). As such, qualifying participants will earn the 5 percent incentive payment for participating in an innovative payment model and taking on downside financial risk for patient outcomes.

Participation in an AAPM is a great way to optimize funding under MACRA, given that the end goal of CMS is to have more providers in AAPMs. However, many providers have struggled to find the right AAPM opportunity.

With its 32 clinical episodes, BPCI-A provides an on-ramp to risk-based payment for almost any provider, including cardiologists, orthopedic surgeons, pulmonologists, gastroenterologists, and other specialists.

2. You see patients in an outpatient setting. 

One of the ways BPCI-A differs from previous bundled payment programs is that it includes three outpatient episodes—percutaneous coronary intervention, cardiac defibrillator, and back and neck (except spinal fusion). Additional outpatient episodes may be included in future model years.

With more and more procedures being provided in an outpatient setting, this added flexibility means that participants in this payment model have the opportunity to select the care setting that will achieve the best outcome at the lowest cost. 

3. You have already begun investing in infrastructure required to succeed in episodic payment models.

Bundled payment programs require participants to have a strong handle on their cost structure so that they can deliver care for the episode at a cost that is less than the CMS benchmarks. Other investments in infrastructure might include care coordination processes and staff, new care protocols, reporting platforms, and compensation redesign. If your hospital system or physician group practice began investing in these new systems and processes to prepare for the bundled payments that were cancelled last year, don’t let those investments go to waste.

4. You are committed to collaborating with other providers on the continuum of care.

Participants in bundled payment programs must communicate and work closely together to deliver better care at lower costs. BPCI-A participants are held accountable for the total cost of care for a full 90 days after discharge or completion of the outpatient procedure. Complications at any point during that period can land the patient back in the hospital and throw the cost structure out of whack. Hospital systems and physician practices that have not already done so will need to identify providers all along that continuum of care who are committed to providing high-quality, low-cost care.

5. You like to test the waters.

Applicants are not locked in on March 12. In fact, signed participant agreements and episode selections are not due until August. In the meantime, CMS will distribute target prices in May so that applicants have time to review them and decide which (if any) clinical episodes provide opportunities for them to beat those benchmarks.