Webinar Presented by:
Darren Horrigan, Director of Care Services
Bryce Henson, Director of Development
Major Medicare bundled payment initiatives like BPCI are designed to improve patient outcomes while reducing cost. After looking at six quarters worth of CMS data, from Q2 2015 through Q4 2016, Bryce and Darren identified that total cost of care decreased by 10.4% and hospital rate decreased by 40%. In their webinar, "Presenting your Home Health Services in the New Bundled Payment (BPCI) Dominated Marketplace," Darren and Bryce discussed the following topics:
- BPCI Program Rollout Overviews
- How BPCI Model 3 Programs Work
- Marketing Strategies for Home Health
- Reporting Needs
- Organizational Changes
BPCI Program Rollout Overviews
Major Medicare Bundled Payment Initiatives:
- April 2013: Bundled Payments for Care Improvement (BPCI)
- April 2016: Comprehensive Care for Joint Replacement (CJR)
- October 2017: Episode Payment Models (EPMs)
It’s important to note that there are two main BPCI Models. A Model 2 participant is a hospital and a Model 3 participant is a SNF (Skilled Nursing Facility) or a Home Care provider.
How BPCI Model 3 Programs Works
Darren and Bryce provided a comprehensive overview of how the BPCI Model 3 program works, shown in the table below. It’s important to note that when it comes to episode of care, you can change how long you want to be financially responsible with 80 days notice. Darren and Bryce note that nationally, most post-acute care providers have opted for 60 days. Hospitals have opted for 90 days.
Episode of Care
Set of services for which the participant is financially responsible for a patient’s care.
● In BPCI, the episode will include almost all services the patient receives in 30, 60, or 90 days after admission to the SNF.
Activity that begins the episode.
● In BPCI, the begins at initiation of of SNF services within 30 days following discharge from an inpatient hospital stay for a MS-DRG the provider has chosen to participate within the program.
Services Included in Episode of Care
All Part A and Part B services (hospital inpatient, hospital readmissions, physicians, LTCH, IRF, SNF, HHA, hospital outpatient, independent outpatient therapy, labs, DME, Part B drugs) are included in an episode of care.
Target Price, Benchmark Price & Discount Price
The target price is the agreed upon total Medicare payment for an episode of care that a provider will be measured against to determine quarterly bonus or penalty payments.
● Target price is based on the provider’s historical spending trended to the current time period (benchmark price) which is reduced by the discount rate (3 percent for BPCI).
For each episode, CMS will compare the actual expenditures for the episode to the target price in a process known as reconciliation, which happens quarterly.
Net Payment Reconciliation Amount (NPRA)
During reconciliation, CMS will calculate the amount that the participant owes to CMS or receives from CMS, know as the Net Payment Reconciliation Amount (NPRA).
● Positive NPRA: Indicates that the participant’s spending was below the target price and CMS pays the participant.
● Negative NPRA: Indicates that the participants spending was above the target price and the participant owes CMS money.
48 Clinical Episodes Included in BPCI Model 3
Darren and Bryce shared that most participants took a look at their financials to determine what they did well, and from there, selected 1, 3, 5 or in some cases all 48 clinical episodes. When looking at your costs, they suggest to look at it from two perspectives:
- Episode Cost
- Diagnosis and provider level
By examining the history of patients you saw over the past two years, you can identify which diagnoses you are excelling at. Darren and Bryce suggest getting a team involved to delve into the data.
The 48 clinical episodes included in the BPCI Model 3 are listed below and are organized by episode category and type.
● Congestive heart failure
● AICD generator or lead
● Cardiac valve
● Pacemaker device replacement or revision
● Cardiac arrhythmia
● Percutaneous coronary intervention
● Cardiac defibrillator
● Major cardiac procedure
● Chest pain
● Other vascular surgery
● Acute myocardial infarction
● Medical peripheral vascular disorders
● Cervical spinal fusion
● Major joint replacement of the lower extremity
● Other knee procedures
● Back & neck except spinal fusion
● Fractures femur and hip/pelvis
● Combined anterior posterior spinal
● Major joint upper extremity
● Complex non-surgical spinal fusion
● Hip & femur procedures except major joint
● Medical non-infectious orthopedic
● Spinal fusion (non-cervical)
● Revision of the hip or knee
● Removal of orthopedic devices
● Double joint replacement of the lower extremity
● Lower extremity and humerus procedure except hip, foot, femur
● Major bowel
● Nutritional and metabolic disorders
● Gastrointestinal hemorrhage
● GI obstruction
● Esophagitis, gastroenteritis & other digestive disorders
● Other respiratory
● COPD, bronchitis, asthma
● Syncope & collapse
● Transient ischemia
● Urinary tract infection
● Renal failure
● Red Blood Cell Disorders
BPCI Model 3 Payment and Reconciliation
- Set Target Prices: CMS figured out the average cost and that became the target price that they receive and hold back 3%.
- Upfront FFS Payments: Medicare will pay all Part A and Part B providers who serve patients identified as participating in the initiative using the existing FFS payment system.
- Payment Reconciliation: CMS goes through a reconciliation process and net up quarterly.
Bryce and Darren shared the following examples to better understand the payment reconciliation process:
- Budget for patient was $1,500 but cost was $1,400. CMS owes you $1,000.
- Patient budget was $18,000 but cost was $20,000. You owe CMS $2,000.
Marketing Strategies for Home Health
Darren and Bryce identified the following strategies to implement into your home health marketing plan:
- Find out who your BPCI referral sources so that you can talk their language and understand their needs. Download/export this list into a spreadsheet: https://data.cms.gov/Special-Programs-Initiatives-Speed-Adoption-of-Bes/BPCI-Initiative-Filtered-View/e5a5-c768
- Ensure you’re speaking to the right person. Find out who makes the bundled care decisions.
- Discuss your HHA program strengths: what do you do to improve patient outcomes and prevent rehospitalization? Link back to your data.
- Use your data to highlight your strengths and best outcomes.
Darren and Bryce suggested developing reports based on your home health agency data and to target those reports based on what you’re trying to promote. Having this information readily available for decision makers and clinicians who are discharging the patients allows you to demonstrate your outcomes.
Bryce and Darren highlighted the following four areas when it comes to looking at your data and reporting metrics by discipline, DX or DRG:
- Costs per Episode
- Visits per Episode
- Re-hospitalization Rate
- Urgent Care w/o Re-hospitalization Rate
When it comes to BPCI, the biggest push is on improving patient outcomes. Darren and Bryce recommended the following market-driven operational changes:
- Admit patient within 24-48hrs. (same day if needed): It’s essential to good care started.
- Medication Reconciliation Protocol (confirmation with PCP signing POC/485 and Contraindication Check): Home care nurses doing on day 1.
- DX Specific Clinical Pathways (especially CHF, COPD/Pneumonia, Ortho, etc. Consider UTI as well): Stay with high risk patients.
- Screening Tools (LACE, Fall Risk, Pain, etc.)
- Interdisciplinary Communication Protocols: Be sure to include the Home Care Aide as well.
- On-Call Clinical Visits Before Sending to Hospital Protocol (except in emergency situations).
- SBAR Communication Protocol Review (gives a clear picture to the practitioner giving orders): Establish a good protocol so the clinician understands how to communicate with the physician in order to avoid unnecessary emergency room stays.
Darren and Bryce stressed the importance of developing relationships and communication with the hospital and nursing facilities, and taking patients who are ready for home care. If the patient needs 1-2 more days, tell them that. Accepting patients who are not ready for home care will affect your rehospitalization rates.