BPCI Advanced - 4 things surgeons need to know

Original content created for Stryker ©2019

On October 1, 2018, the Center for Medicaid & Medicare Services (CMS) Innovation Center launched the voluntary Bundled Payments for Care Improvement Advanced (BPCI-A) “to better support healthcare providers who invest in practice innovation, care redesign, and enhanced care coordination.”¹

In many ways, BPCI Advanced (BPCI-A) is an outgrowth of the Model 2 option of the so-called “Classic” or original, BCPI initiative that ended on September 30, 2018 and held clinicians and provider organizations accountable for quality and costs across a defined episode of care 90 days post discharge.^2,3 In BPCI-A, the episode duration begins on the day of discharge for inpatient episodes and the day of the procedure for the outpatient episodes. Participation in BPCI-A is open to both physician group practices (PGPs) and acute care hospitals. Participants may now choose from 32 episodes of care compared to the 48 episodes under the Classic BPCI program. Of these scaled-down episodes, 29 are inpatient and 3 are outpatient. In terms of risk, Medicare-eligible hospitals and PGPs can participate either as Non-Convener Participants that assume all financial responsibility for the episode or as part of a larger group of Conveners that share the risk and help provide support for the episode. ^2,4 All outpatient episodes have inpatient equivalents, meaning that participants can perform certain inpatient procedures as an outpatient episode.²

Impact on Orthopedic Surgeons

As in past bundled payment initiatives for orthopedic surgery, including the Classic BPCI initiative and more recently, the Comprehensive Care for Joint Replacement (CJR) initiative, lower joint arthroplasties are key areas of focus of CMS. Early data shows that bundled payment initiatives have the potential to achieve cost reductions for hospitals, as well as improving quality and reductions in lengths of stay.⁵ With BPCI-A now underway, it’s important to examine how the BPCI-A may impact the landscape for orthopedic surgeons, including some of its key features, as well as areas of potential concern that are important for orthopedic surgeons to consider in participating in BPCI-A. ^5,6

1. BPCI-A qualifies as an advanced alternative payment model under the Medicare Access and Chip Reauthorization Act (MACRA) of 2015.

Of particular note for orthopedic surgeons considering participation, the BPCI-A has created a single payment and risk track for a 90-day bundle, that includes 3 outpatient Clinical Episodes that qualify as an Advanced Alternative Payment Model if certain thresholds are met.¹ Currently, however, CMS has not yet approved coverage for total knee arthroplasty (TKA) in the outpatient setting, although many non-CMS covered TKAs are performed in outpatient settings.⁷ The next application period start date will begin on January 1, 2020.¹

2. BPCI-A establishes the first outpatient episodes under a bundled payment model, with a total of 32 clinical episodes, 29 in the inpatient setting and three in the outpatient setting.²

Of the 29 episodes covered under BPCPI-A, 10 of the inpatient episodes and 1 of the outpatient episodes are orthopedic, suggesting that orthopedic procedures will remain a key area of focus in terms of costs and quality of care.⁶ Under BPCI-A, there are seven quality measures; most notably for orthopedic surgeons, the Hospital-Level-Risk-Standardized Complication Rate Following TKA and THA (total hip arthroplasty) 90 days from the date of admission and the All-cause Hospital Readmission Measure, pending potential approval of CMS coverage for outpatient TKA.^7,8

3. CJR will take precedence over BPCI-A for lower extremity joint replacement episodes.

This means that orthopedic surgeons in physician group practices that are already participating in the CJR initiative will be unable to initiate lower extremity joint replacement episodes in BPCI-A, potentially limiting the participation of independent orthopedic surgeons in CJR markets.⁴ Although the CJR program has since been scaled down, in data compiled in 2016, based on the original CJR program findings, physician group practices reduced costs by $12.6 million performing the surgeries independently.⁴ Further, limiting the participation of PGP’s could also potentially prevent greater opportunities for collaboration and coordination between PGPs and hospitals.

4. Total knee arthroplasty (TKA) has been removed from the Medicare Inpatient Only list.

In January 2018, CMS removed TKA from the inpatient-only list, which means that TKA surgeries may now be performed in hospital outpatient settings.⁸ A potential result of this decision is that that more high-risk patients, with greater comorbidities and who are at-risk for greater complications, readmissions, or revisions, will most likely remain in the inpatient setting, resulting in a potentially higher average cost per episode than past TKA patients in hospital settings.⁸

This material and or presentation is provided for guidance and/or illustrative purposes only and should not be construed as a guarantee of future results or a substitution for legal advice and / or medical advice from a healthcare provider. Stryker Performance Solutions does not practice medicine and assumes no responsibility for the administration of patient care.

©2019 Stryker Performance Solutions LLC

References

1. CMS Fact Sheet, Bundled Payments for Care Improvement Advanced, https://innovation.cms.gov/files/fact-sheet/bpci advanced-generalfs.pdf Accessed February 13, 2019.
2. Health Affairs, Early Participants and Focus Areas In BPCI-Advanced, December 2018. https://www.healthaffairs.org/do/10.1377/hblog20181204.525769/full/ Accessed February 13, 2019.
3. https://www.healio.com/orthopedics/business-of orthopedics/news/online/%7B6e4e8d85-8534-4907-8347 bfef2cc1c923%7D/speaker-discusses-differences-between-bpci-advanced-and original-bpci-cjr Accessed February 13, 2019.
4. A Closer Look at BPCI- Advanced, American Academy of Orthopaedic Surgeons, May, 2018. https://www.aaos.org/AAOSNow/2018/May/Advocacy/advocacy02/?ssopc=1 Accessed February 13, 2019
5. Bundled Payments in Total Joint Replacement: Keeping Our Care Affordable and High in Quality, Curr Rev Musculoskelet Med. 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5577424/ Accessed February 21, 2019
6. https://www.beckersspine.com/orthopedic-spine-practices-improving profits/item/40813-aaos-raises-major-concerns-over-bpci-advanced-model
7. The Shift to Outpatient Large-Joint Replacement Surgeries, Decision Group Resources, December, 2018. https://decisionresourcesgroup.com/drg-blog/shift-outpatient-large-joint replacement-surgeries/
8. BPCI Advanced: Ten key differences from original BPCI https://www.beckershospitalreview.com/finance/bpci-advanced-ten-key-differences-from-original-bpci.html February 12, 2019.