May 10 2019 Amrita Sehgal, Charles Sauter, Josh Loehrer

TAVR Case Study: Uncovering complexities in BPCI-A rules


On April 24, 2019, CMS announced that it will include five new clinical episodes for BPCI-A Model Year 3: Outpatient TKA, Bariatric Surgery, Inflammatory Bowel Disease, Seizures, and TAVR. TAVR (Transcatheter Aortic Valve Replacement) is a minimally invasive procedure that replaces narrow aortic valves. Given the complexity of cardiac procedures and a recorded wide variation in outcomes, there has been a growing number of providers investing in the improvement of cardiac care management processes and the creation of “Centers of Excellence.” With the amount of investment spent in perfecting these processes and procedures, many providers were pleased when CMS included cardiac episodes in BPCI Advanced.


CMS’s complex episode specifications are generally designed to increase ‘fairness’ in performance assessments, incorporating comorbidity-based case-mix-adjustment models. However, Clarify Health’s data science team unearthed how a one-size-fits-all episode design approach across 32 episodes in the BPCI Advanced program could create challenges for participants with growing TAVR programs.

According to BPCI-A rules, if a patient begins an episode with a relevant discharge and revisits the hospital within 90 days of that discharge (i.e., readmitted), the costs of the readmission are rolled into the episode costs for the initial discharge. However, the relationship between PCI and TAVR offers an example of where these rules misrepresent the actual episode. Often, a planned TAVR procedure will include a pre-operative heart catheterization and subsequent PCI if warranted. If a provider is participating in the PCI clinical episode for BPCI-A, then the pre-operative PCI will trigger a PCI episode, and the subsequent TAVR event will count as a readmission in that PCI episode. Thus, the provider would be on the hook for this “readmission” under the BPCI-A program – even if the visit was planned as part of what is actually a TAVR intervention.


While PCI generally had favorable economics for our customers, our performance analytics surfaced how TAVR procedures resulted in very high per-episode penalties when they occurred following a PCI. We worked with our customers to identify the specific financial impact of this and to understand how changes in their TAVR volumes might impact the financial attractiveness of BPCI-A PCI participation. Ultimately, many of our customers with growing TAVR programs elected to hold off on enrolling in PCI for Cohort 1, and instead used 2019 to explore further and prepare for enrollment starting in 2020.


The addition of TAVR as a separate clinical episode for Model Year 3 should encourage more providers to participate in PCI episodes, and potentially a broader set of cardiac episodes that face a similar challenge.

To date, CMS has not released information on other potentially overlapping episodes. However, we expect CMS to clarify this logic and define when a given surgical or procedural episode (e.g., TAVR) would serve as the “anchor” event and take precedence over a pre-procedural event (e.g., PCI) instead of counting as a readmission in the initial episode. Adjusting episode definition to account for planned downstream surgeries or procedures will ensure episodes are fairly accounted for and providers are set up for success.

Learn more about the BPCI-A program in our Resources section or contact Josh Loehrer.


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