I. The effects of COVID-19 on the BPCI-A program 

As healthcare organizations navigate through this era of COVID-19, many have seen that this pandemic has had a tremendous impact on the BPCI-A patient population. BPCI-A program participants have been anxiously awaiting communications from The Center for Medicare & Medicaid Innovation (CMMI) regarding flexibilities in BPCI-A model participation. Just recently, CMMI and CMS announced 3 options regarding model flexibilities, 2 of which will allow the opportunity to sign amendments to the current participant BPCI-A contracts. 

Option 1: Eliminate savings (Net Payment Reconciliation Amount, NPRA) and downside risk by excluding all clinical episodes from reconciliation for Model Year (MY) 3. This option places a pause on the program for participants, as no reconciliation will take place for MY3, which represents the full 2020 calendar year. 

Option 2: Remain in two-sided risk and exclude certain clinical episodes with a COVID-19 diagnosis from reconciliation during the episode. The methodology around how the patients with a COVID diagnosis will be flagged is unknown at this time until further details are provided by CMS. 

Option 3: Remain under the current MY3 participation agreement with CMS, which includes remaining in two-sided risk with all clinical episodes triggered by the organization. This option fosters no changes to what is currently in place for BPCI-A participants. 

CMS plans to release more information around these options at the time they make the various amendments available to BPCI-A participants. CMS has also committed to providing participants with ample time to make their decisions. More information will be forthcoming from THP next quarter. For additional questions in the interim, please don’t hesitate to reach out to your hospital leadership team, THP, or Kristen Klopp, Manager of Bundled Alternative Reimbursement. 

II. Bundle Identification: across the continuum 

Identification of potential Medicare Beneficiaries that may trigger a BPCI-A program clinical episode at the time of the anchor hospitalization and through transitions of care is seen as foundational to successful management of this patient population across the 90-day financial risk time period. As you’ll read below, there are multiple key stakeholder departments responsible for identification of both potential and confirmed or final bundle patients as well as in disseminating that pertinent information through transitions of care. 

a. Inpatient/Acute

Health Information Management (HIM), which includes Clinical Documentation Improvement (CDI) and Coding teams, as well as Inpatient Care Management (CM) are the two key stakeholders that manage bundle-identification work from a hospital perspective. 

HIM: The (CDI) team reviews charts and assigns each case a working Diagnosis Related Group (DRG). The working DRG appears in the Epic Patient SNAPSHOT section of the chart. This working DRG can be updated by this team throughout the hospital stay and through discharge in the event that the medical needs or primary reason for the hospitalization evolves. The Coding team reviews the cases, evaluates for final codes and assigns a final DRG post-discharge. Typically, this process is completely within 4 days of discharge, given all the required coding documents are present. A process exists to further evaluate cases between CDI and Coding in the event that the DRG assignments are not mutually agreed upon. The CDI and Coding processes are centralized to Tower, so the process is consistent across all BPCI-A participating hospitals. 

Inpatient (CM): This team uses the working DRG, once assigned by CDI teams, to identify potential bundle cases. The CM team proactively works with the rest of the interdisciplinary team to appropriately identify if discharge needs or resources are needed and whether placement into a skilled facility or acute rehab center for continued therapy is necessary post-hospitalization. CM will meet with the patient and caregivers to discuss options for the services/needs/placement required. During this process, CM will discuss with the patient and caregivers, the BPCI-A program and the patient’s potential to trigger a clinical episode as well as address any transition questions. 

b. Post-Acute

Population Health: This team runs an External Crystal Epic report daily to identify both potential and final BPCI-A patients. The report pulls in the patients who trigger a bundle working DRG, patients that trigger as a bundle on a registry (driven by Physician use of order sets) and patients who have a final coded bundle DRG. The team has worked with IT to make the report as robust as possible in order to obtain a daily proactive list of bundle patients. The Population Health team then creates an episode of care in Epic. These episodes identify that the patient is in a BPCI-A bundle, which clinical episode and the start date for that episode. 

c. Transitions of Care 

For bundle patients that move across the continuum post-hospital discharge, whether that be to home with Home Health Care or in transitions to Skilled Nursing Facilities, Acute Inpatient Rehab centers etc, there are 4 primary ways in which BPCI-A cases will be identified when transitioning. Figure 1 provides the 4 primary mechanisms to identify BPCI-A patients and outlines current vs future state for these currently evolving workflows. 

Figure 1: Bundle Identification in Transition

Graph displaying the four primary ways in which bundles should be identified
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