BPCI Advanced, Attribution, and Other New Challenges in Payment Reform

A year ago, Congress seemed poised to get rid of the Affordable Care Act (ACA) and cardiologists were preparing for a new mandatory bundled payment model. Today, the ACA still stands, if battered, and President Trump’s first HHS Secretary, Tom Price, MD, began pulling the plug on the Obama-era model literally the day after the American College of Cardiology (ACC) ended in Washington, DC, in 2017.

This year, at the 67^th Scientific Session of ACC in Orlando, Florida, the new posture of CMS was on display as Steven A. Farmer, MD, PhD, FACC, senior advisor and senior medical officer at the Center for Medicare and Medicaid Innovation, took attendees through a detailed explanation of how a new voluntary payment model will work, during the session, “Payment Reform: Update From the Trenches.”

Today was the deadline for physicians and hospitals to apply to CMS if they want to take part in Bundled Payments for Care Improvement (BPCI) Advanced, the “next generation” version of an earlier model that will expire later this year. Farmer said BPCI Advanced takes lessons from BPCI and will differ from it in key ways:

• It is designed to shift care from individual services to clinical episodes, by establishing an accountable party. The panelists agreed that despite BPCI’s potential, one of the most difficult aspects, especially for cardiologists, will be establishing attribution.
• It will be a designated advanced alternative payment model (APM) for purposes of the Quality Payment Program, which means those who take part will not have to participate in the Merit-based Incentive Payment System, or MIPS.
• For cardiologists, there are 8 inpatient episodes and 2 outpatient episodes.
• Farmer detailed how episodes begin, as well as the role of a convener, which is an entity not enrolled in Medicare—neither a provider or supplier—that provides data on assistance in complying with the model. The convener agrees to bear some risk to CMS.
• Benchmark prices for hospitals are based on patient case mix, the peer group, and historic fee-for-service spending.
• Benchmark prices for doctors in practices are based on care philosophy, training, context, and some peer feedback. Farmer said because providers have not done this in the past, this will be phased in.
• Quality measures will include those based on claims through 2020, with others added later.

After the session, Farmer said there’s been intense interest in BPCI Advanced, but it’s too soon to say how many providers will follow through with all the steps to take part in the model come fall. Today’s deadline lets CMS know they need to get interested providers their data so they can evaluate if they want to proceed.

Having good data and using it well is essential to making progress in both quality improvement and cost control, said Cathleen Biga, a cardiology practice administrator in the Chicago area, and Paul N. Casale, MD, MPH, FACC, executive director of NewYork Quality Care, an accountable care organization that includes New York Presbyterian, Columbia, and Cornell. Both Casale, in his presentation and Farmer, in conversation, said the challenge ahead is figuring out how to make the ACOs, which are oriented toward primary care, work with models that are geared toward specialists; as time goes on, the various alternative payment models will all need to work together. Casale noted, for example, that when a patient is assigned to a specialist in cardiology, that physician is not going to be bothered with measures that have nothing to do with his field of expertise.

But ACOs can help promote the adoption of new technology, and care managers are often better than any scoring system for knowing which patients need to be connected with behavioral health or related services. “If you have patients with challenges, get them to the care managers,” Casale said.

The speakers agreed that payment reform is past the point of being new, yet many practices have not adapted. Karen Joynt Maddox, MD, MPH, FACC, outlined the discrete steps practices can take to ease into APMs, and yet many skipped basic reporting requirements under MIPS. Providers need to take this seriously, she warned. While the pace of reform will vary from region to region and from specialty to specialty, “This is not something that is going to fade into the woodwork,” she said.

Biga got down to business, giving the audience measures to focus on and ways to motivate physicians—starting with report cards that let practice physicians see each other’s data. Her advice was specific: every patient needs a risk score, because most models are based on risk. Diagnoses must be specific, and they need to be re-ordered. “Patients cannot be pregnant for 14 months,” she said.

Data are essential, and that means the ability to use electronic health records (EHRs) must be solid. The practice must be on good terms with its information technology team. “We need to have our EHRs work for us," and not the other way around, she said.

She agreed with Casale on a key point: beyond the financial, administrative, and technical infrastructure, a practice embarking on a shift toward APMs must have organization readiness and leadership. Change requires a cultural shift. “It takes convincing the CFO that fee-for-service really is going to go away at some point,” she said. It takes leadership when, “We need to invest in our technology, and we need to make sure we have the right people in the right places.”