Health Policy Committee Update

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What Does “BPCI Advanced” Offer the Orthopaedic Trauma Surgeon?

Douglas W. Lundy, MD, MBA, FACS, FAOA
Health Policy Committee Chair

The OTA Health Policy Committee continues to carefully monitor federal rules and legislation as well as advocate on your behalf for the improved care of trauma patients. There is always plenty going on in terms of healthcare policy, so we have lots to monitor!

One of the big items in healthcare today is BPCI Advanced. As you hopefully recall, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) mandates that physicians must participate in one of two pathways to be completely reimbursed for the care they deliver to Medicare patients starting in 2019. Whether you know it or not, the government is already deciding how well you comply with these pathways, and how you do this year will affect your reimbursement in 2020. As you have probably surmised, your payments in 2019 were decided last year.

The two pathways are the Merit-Based Incentive Program (MIPS) and the Advanced Alternative Payment Model (aAPM). Orthopaedic surgeons will need to decide which program they will participate so that they can receive full reimbursement for the care they deliver to Medicare patients. Up until recently, the aAPM available to trauma surgeons was very sparse, and we hope that BPCI Advanced will be a beneficial pathway for trauma surgeons!

The Bundled Payments for Care Improvement (BPCI) Program launched in 2011, and it is a voluntary program that encourages orthopaedic surgeons to improve care and decrease cost in many areas including spine, total joint arthroplasty and lower extremity fractures. The BPCI program expected hospitals, providers and post-acute care to work closely together. Although many orthopaedic surgeons have been profitable in BPCI, the success of the overall program is unclear. The Lewin Group reported “BPCI participants have responded to BPCI incentives, but there are relatively few instances in which these responses significantly changed key outcomes. Because of the large number of situations encompassed under the initiative, including the selective and heterogeneous group of participants and limited and varied experience of participants, it is challenging to reach conclusions about the overall impact of BPCI.¹”

None the less, the Centers for Medicare/Medicaid Services (CMS) has announced that BPCI Advanced will begin on 1 October 2018 for thirty-two different care episodes (twenty-nine inpatient and three outpatient)². This is a voluntary program that has a single, retrospective payment with a ninety-day clinical episode period. This single payment covers the entire cost of care associated with that patient during the ninety-day episode, and the hospital, physicians and other entities must split up that payment. There are opportunities that an acute care hospital or a physician group practice can serve as a convener or a nonconvener. Though beyond the scope of this article, this difference affects how much risk a physician group takes in terms of other providers during the bundle period.

Episodes under BPCI Advanced include the following that might be applicable for an orthopaedic trauma surgeon:

  • Double joint replacement of the lower extremity
  • Fractures of the femur and hip or pelvis
  • Hip & femur procedures except major joint
  • Lower extremity/humerus procedure except hip, foot, femur
  • Major joint replacement of the lower extremity
  • Major joint replacement of the upper extremity

Physicians participating in BPCI Advanced will have to report certain Quality Measures to CMS for the patients in this initiative. Two will be required for each episode of care:

  • All-cause Hospital Readmission Measure (NQF #1789)
  • Advance Care Plan (NQF #0326) 

These five quality measures will only apply to select Clinical Episodes:

  • Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF #0268)
  • Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF #1550)
  • Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF #2558)
  • Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (NQF #2881)
  • AHRQ Patient Safety Indicators (PSI 90)

Needless to say, this is a complicated plan that will not be utilized by everyone. For more details, please check out the references below.

  1. CMS BPCI Models 2-4: Year 3 Evaluation and Monitoring Annual Report, Final October 2017, https://downloads.cms.gov/files/cmmi/bpci-models2-4yr3evalrpt.pdf.
  2. https://innovation.cms.gov/initiatives/bpci-advanced