In the acute care space, Medicare, Medicaid, and many Commercial payers are looking at bundled payment programs as a vehicle to transition into the value-based care landscape. Choosing the correct bundled payment program to participate in is critical for success. Healthcare organizations must have visibility into past performance, accurate target pricing, operational opportunity areas, and performance improvement results.
In 2018 the Centers for Medicare and Medicaid Services (CMS) Innovation Center announced a new pilot program called Bundled Payment for Care Improvement—Advanced (BPCI-A). This program, while currently offered as voluntary participation, follows the same path as the Comprehensive Joint Replacement program which became mandatory following the pilot period. The BPCI-A program offers the potential of significant gainshare for superior performance in addition to a 5% Part B bonus paid as part of the Quality Payment Program’s Advanced APM pathway. BPCI-A has been designed to be broad in its impact and coverage across clinical service areas.
As provider participants consider the 30 clinical bundles, they need to choose wisely on the basis of their knowledge and insights into past performance trends. Initial market data indicates that hospitals would like to limit their risk exposure initially, as they “learn” how this model works, before exposing a wider segment of their medical services portfolio to significant revenue risk. They seek a structured, data-driven decision-making framework that combines insights with heuristics from caregivers who have a deep understanding of the local market and population.