So, at this point, Jim Blankenship is going to talk to us about the BPCI advanced model, particularly around acute myocardial infarction. Many of us know Jim of Sky President, Master Sky, and also now head of cardiology at the University of New Mexico. Jim has a lot of experience in the payment reimbursement space, so I'm really looking forward to this. And, Jim, we'll turn it over to you. Thanks for the opportunity to be here today and talk to you. I'm happy I got assigned this topic because I think it's really fascinating, and I will try and communicate some of the funny little things about it so you can maybe laugh a little bit as we go through. At the beginning, I would challenge you to think as you go through this, who is making money off of the BPCI, the Bundled Payment for Care Improvement, advanced system? And I'll give you the answer, or at least one answer, at the end. But some of the lessons that I'll try to convey here have been given by our other speakers. And as is so often the truth, if you hear something coming from multiple people, probably out of listening to it, it's likely to be true. So we'll talk about innovation models, the forerunner of BPCI advanced, as far as BPCI, and then BPCI advanced, and then finally, take a look at the results, should be BPCI advanced results. As has been said, CMS's strategic plan is shown here in its most recent innovation, and one of them is to drive innovation. And as has also been mentioned, CMS has the goal of getting 100% of traditional Medicare patients into ACO-type relationships by 2030. So one bottom line is that this is coming, and if it hasn't gotten to you yet, it will in one way or another. CMS plans to do this through value-based care, and you can see the second from the left here is Bundled Payments, which is what I'm talking about. And so you see this is squarely in the sites of CMS. So we'll talk about innovation models a little bit in general to try and put into perspective where BPCI advanced fits into this. I'll note that the CMS innovation models, the Innovation Center, says that they're developing new payment and service delivery models in accordance with the requirements of Section 1115A of the Social Security Act. And in fact, as has been mentioned, CMS is going to town on this. You can see these are 20 of their models, and they have another 65 that I do not have room to fit onto here, but at the top right, one of those is BPCI advanced. And again, they're rolling out new ones all the time. This is from just one week ago. They turned out their All-Payer Health Equity Approaches and Development model just one week ago, which is going to run for 10 years and picked up by selected states. So by the time they finish this talk, they may have rolled out another model. They've got lots of models. They're trying, seeing if something works. The models are all around us, and as someone else said, you may not even know if you are participating in them. This is my little old state of New Mexico. You can see all the models that are here, including 13 in my town of Albuquerque, a system where there's only three hospitals. So there are plenty of these models going on right around me, and I don't even know where they are. And in fact, about two years ago, we flirted at the University of New Mexico with BPCI advanced. I remember them talking about it. We in cardiology were not consulted, but they said they were going to try it. And in fact, they shadowed the program for a year to see how we would do, and they decided that we would make money, but they also felt that we did not have enough patients to qualify or to make it viable, so they ended up dropping it. But there again, that was something that they didn't consult me, and I was lucky to even find out they were thinking about it. Let's talk about the bubble of payments for care improvement, which is the forerunner, and you'll learn why we went on to the advanced version. But this was from 2013 to 2018, and the results generally show that it did not improve quality. CMS lost money, and they found that while there were lower costs for patient care, the payouts to providers led to CMS losing money overall. So it's not surprising that they quit that one and came up with something else. Just to dig into it a little bit, for the BPCI, the savings for PCI were $71 per case for bypass surgery, $127. In fact, the only thing where it really worked well in the cardiology space seemed to be for congestive heart failure episodes. So I would call that an epic fail. The final evaluation was by the Lewin Group, a consulting firm, two years after it ended, and they concluded the following. They said, our results were consistent with previous reports. That demonstrated the initiative has resulted in a reduced episode of payments that was driven by declines in institutional post-acute care, that is, nursing homes and home health care, as well as payments to providers and hospitals. It did maintain the quality of care, but again, Medicare ended up losing money on it. Since one of their goals is to save money, it's no surprise that they canned this one, which leads us to BPCI Advanced, which is their next version and their hope of being able to recoup some costs. So this is a comparison. This slide and the next simply show that less rich engaged in BPCI Advanced. In fact, the number has fluctuated wildly during COVID. But the key differences are here. The Advanced version is going through 2023, now extended through 2025. All of the bundles are 90-day, whereas previously you had a choice of which you participated in. You can lose up to 10% of reimbursement if you do not maintain quality. The excluded services that are not counted in the costs that are attributed to you are very few, whereas in the previous version, it was a more liberal set of ones that were developed based on clinician advice as to what was unrelated to the procedure or the model that you were in. The target prices are set at the end of the year, not the beginning. And most importantly, as was noted earlier, it does qualify as an Advanced Alternative model, so you are eligible for that 5% bonus, which probably accounts for why it's not doing well in terms of the money aspect of things. So there are eight cardiology categories here, general categories, but the ones that are most notable for cardiology is the acute MI and the PCI for inpatients and the PCI for outpatients. These are the ones that we can pay attention to. Now, if you want to really understand it, CMS published a 36-page guide showing all 36 steps to how they construct the clinical episode and decide on payments for it. I'm not going to take you through 36 pages or 36 steps, so you can relax about that, but I will point out that it is, in fact, very complex. Here's the condensed version of 36 steps and 36 pages. It's based on a timeline, so you have this timeline, which is this horizontal blue bar, and you have an initiating claim or an initiating episode. It could be an initiating outpatient procedure or an initiating hospitalization. That's where it starts the timeline running. Something that happens before it doesn't really count, so you're not going to worry about that. But starting at the time you have your initiating event, you have 90 days, and anything, any cost accrued to that patient that CMS pays for are represented by these little triangles. I'll explain the little triangles to you here in a second. All of these top ones here are included in the calculation of costs to the patients. These are all ones that ultimately get matched up against the target price that CMS set, and either these are higher than the target price or lower than the target price. As also has been mentioned, some of these are ones you have control over, and some of them are not. For instance, in this particular case, you might say, if you get a PCI and then you put in an entala at the same time, maybe here you're repositioning the entala, and here you're taking the entala out. You're kind of responsible for some of those costs. Say that you put the entala, and say they put the patient on ECMO, now you have all of the ECMO charges that you're not really responsible for in your patient, but you have no control over them. Any ones like this, for instance, the hospital services that we just mentioned, the hospitals can do what they want. You really have no control over that, but it certainly is included in the costs that are ultimately attributed to you since you did this initiating event here. Then finally, these ones on the bottom here, these represent costs that are excluded. I mentioned that the advanced version excludes fewer services than the previous one, but this example might be here, say, as you're taking the patient back to the room after you did your PCI, and they drop them on the floor and break a leg, then that would be included here, because that's not really attributable to anything that led to the patient's admission or to the care that you provided. Again, there aren't many of these. The way the whole system works is that basically CMS sets a preliminary target price for each service. That's based on your hospital's prior performance, characteristics of the patient treated previously, the hospital's peer group characteristics and terms. They take their benchmark, which is their calculation of all those costs, and then subtract 3%, and that's your target price. I mentioned that it's complex. This is the calculation of benchmark prices, and any time you see formulas like this, it's way beyond my level of understanding. As I said, it is complex. For each service, CMS pays the hospital as normal, kind of like the fee-for-service model that you normally work under and like some of the other ACO plans. They pay the hospital for all the normal charges, and then they reconcile at the end. At the end, they calculate the final target price, which is basically the same thing they did at the beginning, but it's adjusted for the actual characteristics of the patients that you ended up treating during this period. They compare what they actually paid out, what the target price was, and if they paid out more than the target price, then you get to pay them back. If they paid out less than the target price, then they pay you some extra. Then, of course, there's the 5% for being in an APM. Let's see how that works out. The results are still sparse, but this article in JAMA indicated that decreased patient care costs by $79 million, but increased spending by Medicare by $279 million. In other words, the same thing you saw with DPCI, where the actual cost of providing care went down, but presumably the administrative costs and incentives and so on ended up costing Medicare money. This is a little more of a deep dive by the Lewin Group that I published during this year. They concluded that for the average surgical bundle, there was actually $1,800 cost savings, and for the average medical bundle, there was an $800 cost savings, but the net loss to Medicare was still 1%, and there was no real change in the quality metrics. Just to summarize here, the total payment for care improvement advanced is one of many CMS innovation models that's designed to improve quality and decrease cost, but it has not really improved quality. It's kept quality stable, and it hasn't decreased cost to Medicare. It falls on DPCI, which had little or no success, and DPCI advanced may be more successful, but so far, it's not looking particularly positive. The data is still sparse and somewhat conflicting. It's being collected, and we'll see, but mostly, the descended results are really not available yet. I would pose at this point the same question that I posed at the beginning. Who is making money off of this? It's not the hospitals. Maybe the providers rich in hospitals are getting that 5% incentive for the advanced practice model participation. It's not Medicare, but I will point out that if you're interested in learning more about it, there are plenty of groups and conferences to go to, and they'll happily take your money. You can see some of the ones that have been going on over the past few years here. You missed the 2023 Healthcare Bundle Payments Conference in Nashville. That was this spring, but there's still time to sign up for the third virtual Value-Based Payments Summit Special Edition, which is coming January, February of this winter. So there's still time to sign up and get all the rest of the information. So thanks for listening, and I appreciate the chance to be able to be here and talk. Thanks, Jim. As always, a great overview and information there. And I would say for the listeners, if you wanted to go after this presentation and read more about it, I think the BPCI models are probably the most impactful, biggest interaction in cardiology, as far as directly and specific to our practice. Now, whether that will continue probably depends on whether or not Medicare actually saves money with the BPCI advanced or if they end up shoveling it and going a different direction. But I think an important program to be familiar with.

BPCI advanced model

acute myocardial infarction care

CMS

value-based care

alternative payment model