Ayin's bundled payment programs

May 20, 2019


With the rapidly increasing shift from volume-based healthcare to value-based reimbursement and care delivery models, healthcare delivery systems face challenges at every turn. Gaining provider buy-in, ensuring stakeholder visibility, measuring performance, analyzing the impacts of shifts in reimbursement models and scaling pilot programs are just a sampling of the challenges.

Business Opportunity

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.

Healthcare organizations must have visibility into past performance


The BPCI-A Decision Support Service combines a set of services that utilize advanced data analytics to assess risk and pinpoint clinical service lines with the greatest opportunity. Our consultants supplement the analytics with an assessment of characteristics in four specific areas:

1. Financial ROI: Utilize historical data to assess the revenue potential for each bundle based on volume, cost trends, and sensitivity analysis to outliers. This part of the assessment involves the application of advanced analytics tools to study trends over 3-4 years of historical data.

2. Operational Readiness: An assessment of ability and preparedness of the organization to integrate operational aspects of episodes including early identification of patients, coordination of care management, and post-discharge planning to minimize risk of readmissions within the anchor period.

3. Post-Acute Network Readiness: Research indicates that a bulk of uncontrolled costs in a bundle payment model is incurred in the post-discharge/post-acute care settings where there is variable coordination with SNFs and other post-acute facilities where the patients go after they are discharged. The ability to operate closely with a network of SNFs, rehab facilities, and home health services so that there is close coordination with staff in these facilities before, during, and post-discharge from these facilities is crucial to manage cost and achieve high-quality outcomes. The service assesses the existence of such operational coordination with post-acute facilities.

4. Data & Informatics: This aspect of the service assesses preparedness of the facilities key informatics infrastructure such as EHR workflow, capabilities to identify and track patient through the bundle life cycle, and analytics capabilities to synthesize clinical and claims data feeds to support operations.

In particular, the financial data analytics tool that is used to assess ROI provides the following capabilities to support decision making:

• Deep analysis of past performance versus target price with flexibility to drill into single or multiple facilities, providers, underlying DRGs or prepare analysis across the entire organization.

• Variation in spend across three years to assess how consistently an episode group is managed across a care entity and highlights outliers.

• Variation by category provides comparison to average data and allows a provider to drill into specific spend categories for summary data against benchmark or detailed data to identify and target areas of opportunity.

We seek a structured data-driven decision making framework


The BPCI-A Decision Support Service provides a structured solution to simplify the analysis of a complex set of parameters to support a provider’s decision-making process by:
• Reducing technical and administrative cost associated with analysis of historical data.
• Leveraging depth of expertise from a consistently top-tier star ranked health plan – with skills and proven expertise in the implementation of value-based models.
• Pinpointing areas of opportunity to limit and calibrate risk exposure.