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CMS Woos Providers With More Gains, Less Risk in Bundled Payments

Analysis  |  By Gregory A. Freeman  
   January 22, 2018

"CMS is prioritizing physicians this time around, and BPCI Advanced now provides the first chance for specialty providers to qualify for Advanced APMs under the MACRA Quality Payment Program," Macmillan says. "In the original BPCI model, specialists proved to be very successful at lowering the costs per episode and improving outcomes for patients."

A revenue opportunity

The new BPCI structure means that, more than ever, CFOs should look at bundling as a revenue opportunity, says Clay Richards, CEO of naviHealth, a Cardinal Health company that assists hospitals with BPCI.

"We think this is a pretty significant revenue opportunity over the next several years. This is a very positive, strong signal from the administration that there is going to be an emphasis on value-based care and a shift away from fee-for-service," Richards says. "Hospitals are going to continue to be nudged in the direction of getting paid for value rather than getting fees for service."

BPCI Advanced participants can be "conveners" or "non-conveners." Conveners are companies such as Archway Health and naviHealth, which take on risk for downstream entities as they facilitate coordination among episode initiators. Non-conveners are acute-care hospitals or physician group practices that initiate episodes but do not take risk for downstream entities.

"We think there will be significant interest from the hospital community to participate in this program," Richards says. "You can select the episodes and the market you want to participate in, so you're not mandated to move forward but you're encouraged to be thoughtful and selective in how you move into value-based care. Hospitals are not being told they have to do this, but they're being given incentives because, ultimately, this is where everything is going, and hospitals need to start finding the best path to get them there."

Previous BPCI participants have proven that both large urban hospitals and smaller rural facilities can be successful with bundled payments as long as they are willing to make the right investments, Richards says.

"Our recipe has been a pretty deep investment in clinical analytics. You have to be able to digest a large amount of clinical and claims data to understand what the opportunity looks like, and you have to invest in the technology and analytics to be able to execute against the program," Richards says. "You also have to have an organizational commitment to some real clinical care redesign, especially for what happens when patients leave the hospital."

Richards notes that the eligibility for the MACRA Quality Payment Program will be beneficial to hospitals as they look for different ways to affiliate with physicians.

"Hospitals will choose to participate as a way to drive the patient experience and differentiate yourself in the market, because quality and the patient experience will improve in this program," he says. "The ability to qualify as an APM will let you build physician alignment models around the program, and now the biggest reason to participate is the financial opportunity it presents to the hospital. To be successful in this program you have to reduce variation and costs in the post-acute side, not so much in the acute setting where you may feel like you've maxed out your strategies, so hospitals can look for opportunities to save money outside the four walls of their hospital." 

Gregory A. Freeman is a contributing writer for HealthLeaders.


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