BPCI-A Update & Trends in Value Based Specialty Care - March 11, 2021 Proprietary and confidential - AAOE
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BPCI-A Update & Trends in
Value Based Specialty Care
March 11, 2021
Proprietary and confidential 1
Today’s Presenters
Dave Terry, CEO Don Schreiner, CEO Keely Macmillan, SVP
Archway Health OrthoIllinois Policy & Solutions Management
Archway Health
Archway Health / info@archwayha.com / (617) 209-7985 Proprietary and confidential 2
Outline BPCI-A Update ▪ Model Year 4 Programmatic Changes ▪ Recent Market Changes ▪ Participation Consideration for Orthopedic Groups Trends in Value Based Specialty Care ▪ Commercial Market ▪ Medicare Direct Contracting Program Questions & Answers Archway Health / info@archwayha.com Proprietary and confidential 3
BPCI-A Update
Proprietaryand
Proprietary andconfidential
confidential 4BPCI-A Update: MY4 Programmatic Changes
▪ Shift from bundles to service lines
▪ Orthopedic & Spine SLs
▪ Updated MY4 pricing model
▪ Switch back to “Realized Trend,” No longer prospective trend
▪ Advantageous for MJRLE
▪ Removal of PGP Offset
▪ Prices tied exclusively to hospital, not group
▪ More specific Risk Adjusters for MJRLE related procedures
Archway Health / info@archwayha.com Proprietary and confidential 5MY4 Orthopedic Service Lines Archway Health / info@archwayha.com Proprietary and confidential 6
Changes in PGP Prices MY1-MY3 vs MY4
In MY1-3, the historical efficiency of the PGP impacted the price through the PGP Offset. In
MY4 the PGP Offset is no longer applied. As such historical performance for the PGP does
not affect Baseline or Reconciliation prices.
PGP Pundle Hospital PGP Relative PGP
= x x
Year 3
Model
Price Benchmark Price Case Mix Offset
Peer Group
PGP Bundle Hospital PGP Relative
= x x
Year 4
Model
Trend (PGT)
Price Benchmark Price Case Mix Adjuster
Accounts for the PGP’s case-mix Makes Trend Factor
relative to ACH’s case-mix. retrospective.
© Archway Health 2021 Proprietary and confidentialAdditional MJRLE Risk Adjusters
In MY3, Major Joint of Lower Extremity Bundles were set too high for knee procedures, and too low for hip
procedures. In MY4, the nuances in the costs of various procedures is introduced to the target price predictions by
creating sub-groups of patients with the following procedures.
# of Episodes
MJRLE (Combined)
MJRLE (Knee)
1.Partial Knee Arthroplasty, MJRLE (Hip)
2.Total Knee Arthroplasty,
3.Partial Hip Arthroplasty,
4.Total Hip Arthroplasty and Hip Resurfacing
5.Ankle and Reattachments
Episode Expenditures
● With this change the general differences in costs for treating patients with a Partial/Total Knee Arthroplasty
or Partial/Total Hip Arthroplasty vs. those without are also reflected in different target prices.
● Similar patients who had the same (PCMA/Target Price) in MY3 will now have different PCMA/Target
Prices for each combination of the above risk factors.
● This corrects the generally high target prices for knees (lower) and low prices for hips (by raising these)
Archway Health / info@archwayha.com Proprietary and confidential 8BPCI-A Update: Market Changes
▪ Large Orthopedic convener stopped offering BPCI-A convener services
in early December
▪ Episode Initiators with that Convener no longer able to participate in the program as
traditional EIs
▪ Medicare unable to allow EIs to switch conveners or become own
convener
▪ All dropped EIs removed from program effective 1/1/21
▪ Only way for non-participating Ortho Surgeons to move forward in MY4
of BPCI-A is to shift Medicare billing to a participating Medicare TIN
Archway Health / info@archwayha.com Proprietary and confidential 9BPCI-A Participation Considerations for Ortho Groups
1. Select surgeons to participate ● High episodic volume
● Strong historical quality & episodic cost performance
2. Select a convener partner able to assign ● This specific structure needs to be established
surgeons to a participating TIN ● Specific legal agreements and billing model required
3. Work with a convener who will provide ● Absolutely allowed by CMS
access to your historical data ● Assess historical performance vs prices
● Benchmark opportunities for improvement
4. There are no CMS imposed deadlines ● Surgeon NPIs can re-assign Medicare billing to a new TIN
at anytime
5. Maintain your own Medicare billing ● Important for managing funds flow and FFS billing
reconciliations
6. Leverage BPCI-A to prepare for new ● Medicare Direct Contracting
VBC contracting opportunities ● Medicare Advantage
● Commercial
● Direct to Employer
Archway Health / info@archwayha.com Proprietary and confidential 10BPCI-A Data Access
BPCI Advanced Participation Agreement
12.2.G (page 58) The Participant (convener) may reuse original or derivative data without prior written authorization
from CMS for clinical treatment, care management and coordination, quality improvement activities, and healthcare
provider incentive design and implementation, but shall not disseminate individually identifiable original or derived
information from the files specified in the Data Request and Attestation to anyone who is not a HIPAA CE
Downstream Episode Initiator or Participating Practitioner …(or is) the Participant’s sub-BA, which is hired by
the Participant to carry out work on behalf of the CE Downstream Episode Initiators or Participating
Practitioners...
Email Confirmation from CMMI
“Downstream Episode Initiators and Participating Practitioners are not precluded from gaining access to the
BPCI Advanced Data Portal or receiving beneficiary-identifiable claims data.”
Beth Chalick-Kaplan, DNP, CRNP, FNP-BC, RN, CCM | Analyst | BPCI Advanced | Division of Payment Models |
Patient Care Models Group | CMS Innovation Center | Centers for Medicare & Medicaid Services |
Archway Health / info@archwayha.com Proprietary and confidential 11Importance of Accessing Your BPCI-A Data One of the main reasons for participating in BPCI-A is accessing the unprecedented data provided to program participants. Benefits include: ▪ Assessing historical group and surgeon performance vs BPCI-A prices ▪ Benchmarking performance vs other groups ▪ Utilizing data to improve quality and cost performance - overall and by MD ▪ Gaining advantages in negotiating VBC contracts with other payers and purchasers ▪ Underwriting risk with stop-loss carriers Archway Health / info@archwayha.com Proprietary and confidential 12
Trends in Value Based Specialty Care
Proprietaryand
Proprietary andconfidential
confidential 13Progress in specialty risk contracting in the Commercial and
market has been slow
▪ A recent study cited 5 live commercial specialty risk arrangements,
▪ Several programs have been terminated due to contract complexity & low volume
Purchaser Conditions Notes
Geisinger Health Plan Coronary Bypass Surgery ● Integrated provider & plan
Pacific Business Group ● Total Joint Replacement & Spine ● Most successful employer driven program
on Health ● Expanding to Cancer and Maternity ● Travel and COE focused
● Still relatively low volume
Multiple large national Solid Organ Transplants ● Longest specialty risk programs
payers ● Essentially discounted FFS
Horizon BCBS Multiple ● Upside only
Central Health Plan OsteoArthritis ● Episode starts at diagnosis
United Multiple ● Many programs terminated due to low volume
Source: AJMC: Successes and Failures With Bundled Payments in the Commercial Market, October 2, 2020 Proprietary and confidential 14Medicare Direct Contracting Program: Structure
Contract between CMS and DCE Direct
• Prospective PMPM payment • Full Up/Down Risk
Medicare Contracting
• PMPM based on Participant • Quality Withholds
Provider partnerships Entity • Annual Reconciliations
• Annual Full Cap Benchmark
Required optional
Specialist Partnerships
Primary Care Primary Care Primary Care
Participant Participant Participant CardiacPreferred
Musculo Cancer Diabetes
Neuro
Providers Providers Providers Care Providers
Skeletal Care Chronic
• No effect on alignment
• Option to be paid by DCE
• Required Contracts • Responsible for quality Participant Providers Preferred Providers
• Determine alignment • Paid by DCE • Determines alignment • Doesn’t drive alignment
• Drives Primary Care cap • Need to get to 5,000+ • Drives Specialty Cap • Can drive specialty Cap
payments lives to start payments payments
• Paid by DCE • Can be paid by DCE
Proprietary and confidential
Archway Health / info@archwayha.com 15Medicare Direct Contracting - Global Risk Model
Game Changing Attributes
1. Prospective Payment ACO Model ▪ Monthly PMPMs paid to DCE
▪ Moves Medicare FFS patients into risk model
▪ Most attribution will be Primary Care driven
▪ DCE keeps all savings and responsible for all
2. Not a Shared Savings program losses
▪ 2% initial discount
▪ 25% Up & Down Risk Corridor
3. Significant Incentives for ▪ Specialty PMPMs flow to DCE if they have
Specialty Risk Arrangements downstream specialty partnerships
▪ DCE success will require partnerships with
high performing specialists
Archway Health / info@archwayha.com / (617) 209-7985 Proprietary and confidential 16Medicare Direct Contracting Entity - Global Risk Model
Budget by Specialty Area
$878 Per Member Per Month $52.7 Million Annual Budget
5,000 Medicare Beneficiaries
Source: Institute for Health Evaluation & Metrics, University of Washington
Archway Health / info@archwayha.com Proprietary and confidential 17Key features to fulfill program goals
Capitated payments Benefit Enhancements Outcomes Metrics
Based on performance year Enhancements and waivers can DC has a small set of quality
benchmarks, option between: be provided to beneficiaries, this: manageable quality measure
Total Cost of Care Capitation Increases compliance All-cause readmissions
Primary Care Capitation Disburdens providers Unplanned admissions
Helps fulfill goals by: Benefit enhancements will Days at home (High Needs)
Improving cash flow include such mechanisms as: The quality measures set is:
Supporting reinvestment SNF waiver Telehealth Outcomes focused
Creates flexibility for downstream Home visits Cost-sharing Centered on preventable admits
VBC arrangements Rewards
PBPM $
Archway Health / info@archwayha.com Proprietary and confidential 18Medicare Direct Contracting - Global Risk Model
Keys to Success
Primary Care Specialty Care
▪ Ability to transition from FFS to Capitation ▪ Preferred referral partnerships with DCE’s
▪ Expanded PCP panel size ▪ Ability to use data to demonstrate great outcomes
at value based prices
▪ Greater use of Care Extenders
▪ Ability to take and manage risk
▪ Patient engagement & Telemedicine ▪ Pay for Performance
▪ Bundles
▪ Patient risk segmentation ▪ Carve-Outs
▪ Chronic care management ▪ Easy access
▪ Preferred partnerships with High Quality ▪ Collaborative, high quality hospital and post-acute
Value Based Specialists partners
Integrated patient engagement tools
Risk financing & Stop-Loss
▪
▪
Archway Health / info@archwayha.com Proprietary and confidential 19Key Takeaways
Archway Health / info@archwayha.com / (617) 209-7985 Proprietaryand
Proprietary andconfidential
confidential 20Additional Opportunities in Value Based Specialty Contracting
◆ The Commercial market is still moving slowly
◆ The Medicare Direct Contracting program is poised to dramatically change the way
specialty care is delivered and paid for
● Capitalize on BPCIA data to
○ Assess your performance vs competitors
○ Identify opportunities vs benchmark performers
○ Engage in contract negotiation
○ Prepare to enter risk arrangements
● Understand local market - what DCEs are in your market?
● Evaluate Participant / Preferred Provider opportunities in Cohort 2 and beyond
◆ Specialists who are prepared to enter into risk based arrangements will win big relative
to competitors
Archway Health / info@archwayha.com Proprietary and confidential 21Closing Remarks on BPCIA
◆ There are still opportunities for Orthopedic groups and surgeons to participate in
the final three years of the program
● Surgeons can start in the program at anytime, there are no CMS imposed deadlines
◆ Choose your partner wisely
● Make sure you get can access to your data
● Fully understand your Pricing, Performance, Opportunities and Risks
● Maintain control over your billing process
● Prepare for participation in Direct Contracting & other emerging specialty risk
arrangements
Archway Health / info@archwayha.com Proprietary and confidential 22Questions & Answers
Contact us at info@archwayha.com
Archway Health / info@archwayha.com Proprietaryand
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