June 14 2018 BY: Sarah Chen, MD

Need a second opinion on BPCI-A?

So, your internal analytics team has received the data from CMS and is hard at work crunching numbers to determine which episodes you should pursue in the BPCI Advanced (BPCI-A) program. Or maybe you wanted to avoid the headache and your organization is relying on a vendor to provide a diagnostic. Did you know that many diagnostic providers have opted not to invest in replicating CMS’s target pricing? In other words, many vendors may be passing off re-packaged CMS numbers as insights.

While this may not seem critical on the surface, this is hugely important for actually determining your ability to capture value under the BPCI-A program. Many surface-level diagnostic reports can show you which episodes might be more expensive but without the ability to replicate target prices, such analytics can’t predict how you are likely to perform in the program going forward.

If all of this is making your head swim, don’t worry. We’ve broken down 6 key facts about the program to help you assess if your analytics team is prepared for the level of statistical modeling required for success in BPCI-A.

1. CASE-MIX ADJUSTMENT GOES FAR BEYOND DRG
Where 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.

Clarify’s case-mix adjustment models take into account an additional 200 factors on top of those used by CMS.

2. YOU’LL NEED TO BE ABLE TO PREDICT YOUR TARGET PRICE IN REAL-TIME
Unlike previous programs that calculated a DRG-level target price, your BPCI-A target prices are assigned on a patient-by-patient basis, based on the presentation factors of each individual patient receiving care.

The target price you receive from CMS is based on your historical patient population and in effect, retrospective. The actual target price of a patient who presents on admission could be vastly different. Without the ability to replicate CMS’s methodology for target pricing, you’re essentially flying blind.

3. THE BASELINE SHIFTS EVERY YEAR
In BPCI-Classic, the baseline stayed static (2009-2012). For BPCI-A, the baseline starts with 2013-2016 and is shifted every model year.

4. IT’S NOT ENOUGH TO BE BETTER THAN YOURSELF
It’s a race. Based on CMS’s PAT (peer-adjusted trend) Factor methodology, your rate of improvement must be better than your peers to achieve a bonus.

Clarify customers receive custom benchmarking built into their platform for easy peer to peer comparison at a market, regional, and national level.

5. PGP TARGET PRICE IS BASED ON HOSPITAL PERFORMANCE
A PGP’s target price begins with its hospitals’ performance but is then adjusted for the physicians’ performance. For PGPs formed after 2016 or with volume <41, target prices will be based completely on the hospital.

6. YOU CAN MAXIMIZE YOUR STOP LOSS BY CHOOSING THE RIGHT GROUPS OF CLINICAL EPISODES
The 20% stop gain/loss is applied across all the Clinical Episodes you choose to participate in. If you’re smart about which Clinical Episodes you participate in, you can maximize the bonus amount you ultimately receive.

The BPCI-A program is the most advanced bundled payment program yet. Is your data team equipped to handle this complexity?

Can your analytics do this? Check out our sample BPCI Advanced Insights report and eBook.

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