Thank you for joining us for the CMS BPCI Advanced Extension Should Your Practice Participate webinar. A few housekeeping notes to get us started. This is a prerecorded webinar, therefore, there will be no Q&A. However, our speakers will provide their contact information at the end of the webinar and we'll be happy to answer any questions you have. Our speakers for today are Matt Civilli, Executive Director at Signature Medical Group, and Jared Knippkamp, Senior Account Manager at Signature Medical Group. I'll now turn it over to Matt Civilli to get us started. Thank you, Raina. So welcome, everybody, who would be logging in and interested in viewing this webinar that we have for you today. We're excited to be here and talk about the BPCI Advanced Program, which is a bundle payment program that CMS administers for Medicare beneficiaries, and the CMS BPCI Advanced Program is in its second iteration, and we'll move ahead to the next slide and tell you a little bit about who we are and our experience with the program, and then cover a little bit of the program itself and for practices that are interested in potentially participating in the program, we will talk about that process and what you should do to prepare yourself. So a little bit about us, Matt Civilli, I've been with Signature Medical Group since 2015. Now the Executive Director, I've been working on both the original BPCI Program as well as the current version of BPCI Advanced, and I also have with me Jared Knippkamp. He is a Senior Account Manager who works on the BPCI Program. He has also been at Signature since 2016 and has also worked on both iterations of the program, working with our clients and partner groups around the country who've participated in this program. So a little bit about us, Jared and I both work for Signature Medical Group, which is a private orthopedic group. We are a proud AAOE member group. We have locations in both St. Louis, Missouri, as well as Kansas City, Kansas, right across the border there from Missouri. And part of what we have done is we have been a participant in the BPCI Classic Program and Advanced Program with our own orthopedic group since the original BPCI Program kicked off back in 2014. What makes us a little bit unique is that we are also a convener in the BPCI Advanced Model, which means we help, from an administrative perspective and an operations perspective, other orthopedic groups around the country help to participate in these different value-based payment arrangements that CMS and commercial payers put on. So you can see a little bit about our experience in the models there on the screen. And with that, we'll jump into a little bit about what the BPCI Advanced Model is. Many of you may have heard about the model over the various years. There's been presentations done at previous annual conferences. There have been webinars done. And I know many of our fellow members have been part of practices that have participated in either a previous version or are participating in the current version. But for our newer members who may not have participated before and don't know much about the program, the BPCI Advanced Model is basically a voluntary payment model that the Center of Medicare and Medicaid Innovation has put together to help test whether linking payments for a clinical episode can reduce Medicare expenditures, all while maintaining the quality of care for their beneficiaries that are attributed to the model. The current version of BPCI Advanced started on October 1st of 2018. That's when the first cohort of participants went live. They had a second sign-up period, which started in January of 2020. And that participation was set to conclude at the end of this year. However, in November of last year, CMS came out and announced that they would be extending the model starting in January 1st of 2024 and extending through the end of December 2025. So with that extension, groups who have never participated in the model or who have participated in the model previously and are no longer participating would be able to evaluate whether or not they would like to participate in the model for the two-year extension. So a little bit about BPCI Advanced, kind of the bones about the program, what it is. So essentially, it is a shift from volume to necessity. The fee for service is no longer sustainable, otherwise Medicare would run out of funds much sooner than expected if something doesn't change. And so what's going on with the patients, they will no longer receive unnecessary utilization. It's not that they're being withheld care, but they are going to receive care based on their specific needs. So historically, patients would have their total knee, total hip, total shoulder, whatever episode they're having done, and then they would go to a skilled nursing facility for 21 days. They would receive home health and then outpatient PT. And all of that is costly, but not all of it was necessary. So taking away the idea that more care leads to better outcomes, just moving to the care that is necessary to provide the same outcome, if not better, at a lower cost. So how the bundle works, the bundle is going to be a collection of payments that take place within roughly a 95-day episode of care. So we're talking about the 72 hours prior to surgery, the admission to the hospital, the physician's cost, and then 90 days post-op. So all of the costs within that timeframe will be applied toward the bundle. And this applies towards any patient, any Medicare A and B patient that has Medicare as their primary insurance. There is no Medicare Advantage or VA. It doesn't matter what the supplemental insurance is. As long as the patient holds Medicare A and B through the entirety of their 95-day episode, they will count towards the bundle. There are some exclusions, but we always like to view that the patient is going to count towards the bundle until they don't. And this is just an example of some of the drastic differences we have seen in cost of unmanaged patients versus managed patients. So as you can see in the yellow, the hospital, the acute care costs, the physician fees, those are going to be fixed. There's nothing that can take place as a result of changing those. But where our clients, where participants in BPCI Advanced have made a huge difference in saving Medicare money is utilization and the post-op, the 90 days post-op, where a patient can still go to a SNF. It's just not necessary for them to go 21 days, which is the Medicare allowable. So they only need to be at the SNF for five days. So they're saving roughly, depending upon your area, depending upon the skill nursing facility, on average, $8,000 towards the episode. Home health. If home health isn't necessary and a patient can go straight to outpatient PT, you're talking about a $4,300 savings. So the numbers really add up and it's specific to each patient based on their needs. And then the total cost, you can see the difference. You know, when managed in the program, it is much less costly, but the patient is having the same outcome as if they were under the fee-for-service model. Why participate in BPCI Advanced? I think this is a question that we get asked frequently, especially with being a provider group ourselves. You'll see that the first bullet point there is the potential for ancillary revenue. Being a provider group, we're always looking for ways that we can increase ancillary revenue for our practices and for our physicians. And BPCI Advanced, for the most part through the years, especially for our group, has been a tremendous opportunity to have a revenue stream that is independent of the Part B payments that we receive for performing the Medicare procedures themselves. It is a risk-based model and the ability to be in a risk share arrangement and earn ancillary revenue is definitely something that has been a big benefit to both the practice and the individual physicians. Secondly, CMS has approved the BPCI Advanced model as an approved APM. So since all of our physicians, for the most part, are submitting for MIPS on an annual basis, being part of BPCI Advanced can help contribute towards meeting those MIPS goals by providing partial QP status by being a part of the BPCI Advanced model. Now, the percentages required to be excluded from MIPS are highly unlikely from our experience to be met just by participating. However, participating in the model, what we've seen is that our physicians have received an increase on an annual basis, anywhere from 1 to 3 percent, just by being part of the model and performing the care redesign activities required in the model. Third, being in the model provides you access to data. One of the most valuable things that we've seen in this model is being able to get a hold of the Medicare data at the beneficiary and the claim level to be able to use that data both to make changes inside of our practice, both on the physician level as well as the group level, to really put together sort of concierge medicine, so to speak, for beneficiaries both on the Medicare side and on the commercial side by just having the power of the data at our fingertips to be able to see what our costs are, see where our patients are going and put together preferred networks of providers in our areas. So that access to data is something, along with the ancillary revenue, that's almost too good to be true when it comes to being able to have that at your fingertips when you participate in this model. The preparation in advance of mandatory bundles. One of the reasons that we wanted to include that on the slide is because as we move into the future of value-based payments, the CMS has announced that voluntary models like the VPCI program, I'll be them successful, the participation level that they would like to see in the model is a little bit less than what they would like. So they have tried to put other mandatory models in place in the past, such as the CJR And so the future of value-based payments, at least on the Medicare side, are going to move into mandatory models. And those mandatory models could come as soon as 2025. So being able to put your practice in the position to have infrastructure in place, which leads me into my next point, will have you prepared if your MSA is one of the markets that they mandate specialists be involved in with regards to bundles. And finally, down here on the slide, the infrastructure that is put into place by participating in the Medicare bundles could also be used to help facilitate commercial bundles. I think that's one of the questions that I get asked a lot is, we've never participated in a Medicare bundle before, but we've been approached by some of our commercial payers because they have done commercial bundle situations in other markets, and they're looking to start one in my state, but I don't know where to start. So I think that putting the infrastructure in place when you participate in these different value-based arrangements can cross over different payer segments and really be a benefit to your practice. So, as you look to evaluate the model, what we wanted to take some time on today is to help talk about what does that evaluation process look like. Right now, where we are in the timing of evaluating the model, which will show a timeline later that can be used as a takeaway as well, is that we have until the end of the month of May as providers to submit an application to CMS to receive our historical data and evaluate whether or not the model is something that would be viable for your group to participate in. And what we've learned along the way is that data analysis is more important than ever. To get the historical data and do an evaluation, you're going to want to look for things like what your average costs are in the procedures that would be included for orthopedics, things like total hip replacement, total knee replacement, both inpatient and outpatient at the hospital setting, not in ASCs or surgery centers yet. And see how those costs are relative to the prospective target prices that CMS would provide at your hospitals. What we've seen is that the advantageous target prices have become very specific to the individual markets the further the program goes along. So since hospital, since the target prices start at the hospital level, each hospital has a unique set of target prices for the different bundle procedures that you could choose to participate in as part of the model. Those target prices, even in the same city, could be different at sister hospitals, at competing hospitals. So you really want to dig into the data and see how your procedure costs over a 90-day period compare to the target prices that CMS gives out if you would request, submit an application to request your data. One of the other things that you should evaluate if you're evaluating, when you're evaluating the model is do you have dedicated infrastructure in place right now to be able to support the participation of the model? Most of that infrastructure would be at the clinical level. So something like a case manager, a nurse navigator, an MA, a PA, someone who could help work with the physicians and the beneficiaries who would be assigned to the model to navigate through a 90-day episode of care. If you don't have dedicated infrastructure in place, we would recommend looking at hiring that infrastructure in advance of going live in the model. Because what we've seen is groups that have been successful and received ancillary revenue in the program are the practices that have invested in dedicated resources both at the IT side as well as the staffing side to put together the infrastructure to be successful in the model. Part of that infrastructure is administrative and physician engagement. If the physicians in your practice want to participate in this model and are willing to make the care redesign changes necessary to do so, that is one of the major keys to success that we have seen over the past eight years for groups that have been able to achieve success in the model and produce positive savings is that the physicians are all engaged and rowing in the same direction when it comes to wanting to participate in these bundle arrangements. And having the administrative support to keep those physicians engaged and keep the infrastructure in place is very important as well. Finally, the last couple things on this slide that we wanted to touch on was that you have to have some sort of access to a technology or analytics platform to be able to help you and your clinical staff be able to process data, really digest what that data from CMS is telling you when they send it to you periodically throughout the program to tell you how you're performing. Being able to have a platform both for the nursing staff to be able to use to track beneficiaries as they move through the 90-day episode and also be able to produce reports, scorecards for physicians to tell you how you're performing financially is something that's extremely important if you're going to evaluate being in the model. So I know groups have used their EMR or in the past for some of these things, but having a dedicated platform through either something that you create internally yourself or through a vendor partner has been extremely important for us and some of the other groups that we have partnered with that have participated in the program. And finally, you really want to have transparency when it comes to your performance. So if you choose to go and evaluate and participate in the model on your own or you're evaluating market partners, being able to get clear and transparent communication around changes to the model, how you're performing financially, and what you could do to improve, are very important when it comes to the evaluation process. So if you are thinking about or if you have submitted an application to CMS to evaluate your participation in the program, CMS is going to provide historical data from October 1 of 2018 through September of 2022. And they're going to provide raw claims data showing costs of the different things that would be included in the bundle. And with this raw claims data, CMS uses some of that to produce the target prices at the hospital level. So they are taking into consideration several different factors in creating target prices, and some of those are specific to your group. But ultimately, you will get to see, you know, patients during this historical period, how long they were going to a skilled nursing facility. Were they going to an inpatient rehab, which is extremely costly? How many of our patients were being readmitted? So whether you go into the program or not, this evaluation of data can provide useful information for the practice, for the physicians, to get an idea of, you know, what their patients, what kind of utilization their patients have been receiving. Because a lot of it is, you know, the patient will have their surgery done, and then the patient will come back to the physician in, you know, six to eight weeks, and, you know, they don't necessarily hear from them again. So this data can be extremely useful, you know, not only for the program, but just for your general information. So what can be compared here is, as Matt mentioned, target prices are extremely important in this program. You know, identifying where target prices are higher, are lower, and then do you have opportunity in the program? You know, if your utilization was high historically, and you have a lower target price at a hospital, it might not make a lot of sense to move forward in the program. Because even if you were to reduce your utilization, you would have to reduce it by quite a bit to meet the target price that CMS is providing. On the flip side of that, if you have lower utilization historically, but a higher target price at a specific hospital, you might have a tremendous amount of opportunity for that ancillary revenue that Matt spoke about previously. So those are all the different things that need to be considered. You know, it is an extremely complex calculation when it comes to target prices and processing the data. You know, it needs to be looked at with a fine-tooth comb and, you know, really understood to make the decision to participate in this program. You know, what's being looked at is the patient case mix adjustment, your unplanned cases versus your planned cases, the other groups that might be performing at a similar hospital, and then, you know, a standard to real conversion ratio, which CMS looks at to make the dollars more real to current time as opposed to the historical period. So where we stand in this timeline, we are at a key station because the portal is going to close in 28 days. So all applications have to be in to CMS if you want the opportunity to participate by May 31st. If you do not get your application in by the 31st, then there will be no other opportunity for you to enter into the program. So CMS will screen the applicants over the summer and then provide the historical data by the end of the summer towards, you know, getting closer to the September time. And then within that time period to assess the data, you will have to make a decision to participate or not by December 4th. And then your participation in the program would start January 1st of 2024 if you made the decision to move forward with the program. Matt, did I miss anything on the timeline? No, I think that the only thing that I would add is we get asked a lot, am I committing to the model if I submit an application to get my data by the end of May? And the answer to that is no. You're not committing to participate by submitting an application to get your historical data. What you're doing is you're putting your hat in the ring to be able to participate at a later date. The May 31st date is the cutoff to be able to submit an application and receive historical data to evaluate the program itself. The decision to participate would not need to take place until early December. So I think that we wanted to, you know, sort of make that distinction that you're not committing to anything if you submit to get your historical data. And if you choose not to move forward, you would make that decision as well by that December 4th deadline. Yeah, and the worst thing that would come out of it is that you receive your historical data and no harm, no foul if you don't move forward. That's just, that's the, that would just be the end of it. Yeah, and on this slide, I think what Jared and I would like to do is just talk a little bit about how you could prepare to participate in the model should you move forward with submitting an application by the May 31st deadline. So some of the things that you should do to prepare over the summer while we're waiting on that historical data to come in would be to evaluate whether or not you have the internal capabilities to be able to manage and administer the program internally in your practice on your own. So, do you have the staff to do that? And are you willing as an administrator or an executive in the program to take the lead on doing everything that it would take administratively to partner with CMS and go at risk in the program? If the answer to that is no, then there are several conveners in the market marketplace similar to us that can help you from a partnership standpoint, do everything that you need to do. Similarly, you could have a convener help you get your application submitted prior to the May 31st deadline. If you're just not sure you have the time or the bandwidth to be able to do that yourself, we're also available to help groups evaluate and submit applications as well. The second thing that you can do to prepare over the summer is start thinking about evaluating software platforms. There's a number of different episodic software platforms in the market that groups have used to be successful. And I think starting to test those, get demos, evaluate those different platforms, whether they're with a convener or a standalone vendor, or you're looking at developing something internally with your own IT staff, I think starting to have the conversation around a software platform and what that infrastructure would look like or cost, etc., is extremely important. Third, start looking at do you have a case manager or someone who could fill that role internally? It is a vital piece of the program from an infrastructure perspective. Having a dedicated clinical resource to work with beneficiaries both preoperatively and postoperatively as they move through the post-acute process is going to be very important. Start interviewing candidates, start working with convener partners to see if they offer that service, or start dedicating your resources internally to see if you have someone who could fit that mold. And the case manager is something that a lot of practices have continued after they have stopped participation in the bundle, or they have expanded case manager roles to patients that are not in the bundle. It's that concierge level of service. It's something that we have seen practices expand upon just as preparation for good care moving forward. And that case manager is also expanding communication to the community, to skilled nursing facilities in the area, to home health agencies, to outpatient PT, developing preferred networks. That's something that can help set you up for success and prepare for BPCI Advanced if you move forward, that you have a network that your patients, when they go to a specific provider, you know that that skilled nursing facility is going to listen to what you think is best for the patient. They're going to follow your lead and get the patient out based on necessity, and not because of their Medicare allowable being 21 days at a SNF. So that community education, getting that set up, and that is going to put you in a strong position to be successful in BPCI Advanced. And finally, you know, the physician involvement. When you get the historical data, they're just informing the physicians, you know, this is your utilization historically, this is how things can be improved. This is, you know, whether it be articles, whether it be data, just letting them know that healthcare is moving in this direction, and getting them involved in making the necessary changes to be cost effective without giving up any level of care. You know, that their outcomes are not changing. They are, in fact, improving, but they're also more cost effective at the same time, and just being informed of different things that they can do that, you know, many practices across the country have been doing to improve their care and cost effectiveness. So that will conclude the presentation on the BPCI Advanced Extension today. Again, we wanted to thank you for taking the time to log in and download and watch this video if you're interested in potentially participating in the model or re-entering the model if you've been in previously. Both Jared and I's contact information is in the slide deck and is up on the screen there now. So we're more than willing to field questions about the model, field questions that you may be having about the application process, or answer any other questions that you may have. So you feel free to email either or both of us at any point, whether it's in the next 28 days as you evaluate potentially participating in the model, or if you do go forward and submit an application, we'd be available at any point this year to help talk about what you should do to prepare to be successful in BPCI. Thank you. Thank you so much, Matt and Jared, for this presentation. Please feel free again to reach out to Matt and Jared with any questions you may have, and thank you for joining us. Have a great rest of your day.

CMS BPCI Advanced Extension webinar

bundle payment program

Medicare beneficiaries

Matt Civilli

Jared Knippkamp

managed care savings

BPCI Advanced Model