June 18 2018 BY: Sarah Chen, MD

BPCI-A Buyers Beware

CMS has released the long-awaited target prices and raw claims files for BPCI Advanced (BPCI-A). With just six weeks left before the August 1st application deadline, many organizations are scrambling to understand their future performance in CMS’s most complex bundled payment program to date. Vendors selling BPCI-A diagnostics are out in full force, but before you buy… beware!

Many of these analytics vendors are over-promising based on poor data and simplistic assumptions. By simply re-packaging CMS’s files, these vendors can only tell you how you performed historically. What you really need to understand is how you are likely to perform in the program going forward and to do that you’ll need far more advanced analytics and a deep understanding of CMS’s rules.

Don’t be fooled into choosing a vendor that can’t support you come October 1st. Properly vet your BPCI-A analytics vendor with these four questions:

1. BEFORE TARGET PRICES WERE RELEASED, HOW DID YOU ESTIMATE THE TARGET PRICE?
Some vendors are claiming to use CMS’s 5% Limited Data Set (LDS) to estimate your target price. That’s only a 5% sample of your organization’s volume, which is nowhere near enough data to accurately capture your historical performance or project your future performance. In addition, were their estimates based on the old BPCI rules or the more complex BPCI Advanced rules?

2. CAN YOU REPLICATE THE CMS TARGET PRICE METHODOLOGY BY EPISODE?
BPCI-Classic case-mix adjustment was based on the DRG. BPCI-A uses more than 100 factors, including demographics, DRG, HCC severity, AMC status, and recent resource use, to adjust for patient complexity on a patient-by-patient basis. Don’t be fooled by one number. This level of case-mix adjustment requires advanced statistical modeling. Is your vendor equipped to handle this? Can they give you a specific physician’s target price? Do they have a data science team?

3. CAN YOU CALCULATE THE TARGET PRICE IN REAL-TIME?
The target price you receive from CMS is based on your historical patient population. In effect, it’s retrospective. The actual target price of a patient could be vastly different based on factors present on admission. Without the ability to replicate CMS’s methodology for target pricing (mentioned above), you’re essentially flying blind.

4. HOW DO YOU ACCOUNT FOR THE PEER-ADJUSTED TREND FACTOR?
It’s not enough to improve compared to your own historical performance. Based on CMS’s PAT (peer-adjusted trend) Factor methodology, your rate of improvement must be better than your peers to achieve a bonus. Does your vendor have national data to forecast peer performance and provide benchmarking at a market, regional, and national level?

You still have time. Regardless of the bundles you select, you will still need to manage your performance to achieve a bonus. Make sure your vendor has the expertise to power your success. Get your guide to success in our BPCI Advanced Insights eBook.

Additional Resources:

The enrollment period for BPCI Advanced Cohort 2 is right around the corner, check out some of our more recent content to learn more.

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