Bundled payment participants face choices on 2020 performance measurement, continued participation

• Current BPCI-A participants will need to decide this fall whether to stay in the program for 2021.
• Some participants’ results worsened in the second year, according to newly released data.
• Decisions on remaining in the program should take into account new options from CMS. 

Provider participants in Medicare’s largest bundled payment program must decide not only whether to remain in the program but also whether to use new COVID-19-related flexibilities in performance measurement.

The more than 1,000 hospitals and physician group practices that remain in the Bundled Payments for Care Improvement Advanced (BPCI-A) voluntary model face some tough decisions this year, with Medicare offering new options in response to the pandemic. Those options came amid massive disruptions in elective episodes and procedures after many hospitals ceased to offer them during much of the pandemic either voluntarily or in response to government mandates.

“For institutions, they’re evaluating whether or not to even stay in the program for [2021] because of the uncertainty and the financial risk,” said John Kalamaras, business intelligence analytics manager at DataGen. “So, they have to judge how they are doing now and if they are going to continue on in the program.”

That decision-making process will occur amid CMS’s recent release of 2019 performance data, which showed worsening performance among DataGen clients.

Unlike during the first year of the program, which began in 2018, not all of DataGen’s participating clients obtained performance bonuses in 2019, and the payouts were smaller for those that received them, Kalamaras said.

Providers must evaluate their options

A provider’s decision on proceeding in the program should be informed by its updated target prices from CMS and its updated case mix. Both factors likely were affected by the pandemic, when only much more acute cases were treated due to hospital restrictions. CMS changes the target as a provider’s case mix changes.

“If their case mix was more acute [in 2020], then their target might be higher than it would be on a preliminary target,” Kalamaras said.

Provider organizations also have some control over their performance outcomes in 2020 by selecting one of three new options from CMS. Those options are:

1. Removing all upside and downside risk
2. Removing just COVID-19 patients from calculations
3. Continuing to participate as usual

CMS recently said it will identify in the data it sends to providers which patients were COVID-19 patients.

That “is very helpful so that participants can do a full evaluation of all three options,” Kalamaras said.

The choice should be driven by separate analyses of providers’ overall patient population in BPCI-A and of their COVID patients in the model.

A basic guide to choosing among the options, Kalamaras said, includes:

• Choosing the third option if the best financial results are seen when evaluating all model participants
• Choosing the second option if the best financial results are seen when removing COVID-19 patients
• Choosing the first option if no positive financial results are seen in either of those analyses

CMS has not specified a deadline for provider decisions on how they want to be evaluated this year. The agency is expected to send out 2021 agreements within the next two months, with responses due in the fall.

Data released on first-year BPCI-A participation

On June 19, CMS released a third-party analysis of the first-year of BPCI-A. Among the details, which did not include performance data:

• Initial enrollment consisted of 715 hospital and 580 physician group practices.
• About 22% of eligible hospitals participated, compared with 13% in the predecessor BPCI model.
• More than half of hospital participants took part in the “congestive heart failure” clinical episode.
• More than two-thirds of practices took part in the “major joint replacement of the lower extremity” episode.
• About 9% of eligible Medicare fee-for-service discharges and outpatient procedures were at a BPCI-A hospital.