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How BPCI Advanced data will unlock opportunities to redesign care


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This past September, CMS provided preliminary target prices and baseline claims data to organizations that participate in or applied to participate in BPCI Advanced Model Year 3.

For some organizations, this will be the first time that post-acute care (PAC) network utilization and details have been available to review. These new insights will be an important component of your organization’s care redesign plan to improve outcomes and reduce expenditures.

So how should you prepare for this influx of data?

Focus on your patient population

With more types of data available than ever before — from program claims and referrals to clinical assessments, electronic medical records (EMR), and more — the sheer volume of data can be overwhelming. There’s also a lag in delivery of program claims that can further complicates the issue.

With a range of data from episodic care to three years of claims data, there’s plenty of opportunity in this imperfect, still somewhat disconnected data. Gina M. Bruno, vice president of value-based care for naviHealth, believes that the data could be “good enough” in many respects, as it gives a more complete picture of the 90-day episode of care than was available previously.

“As time goes on, the picture of what happened to the patient becomes brighter,” explains Bruno.

The data may provide new visibility beyond the patient’s PAC setting, allowing for the potential to shift your organization’s strategy from “volume to value, with respect to care coordination and network optimization” adds Dr. Jomy Mathew, executive medical director for naviHealth.

By reviewing readmission data over 90 days, post-acute care referral patterns, and quality-based measures, claims data can both inform and impact care redesign activity, says Mathew.

“However, by matching real-time data that exists within the electronic medical record (EMR) and other potential sources with the claims, you can get a true barometer of performance,” he says.

A critical part of decision making in managing a patient’s journey during a bundled episode of care is PAC setting choice at the end of a hospital stay. It’s no longer enough to just answer the question “where to next?” but rather determine clinical appropriateness (drawing on expert insights from clinicians) and leverage quality network providers. This ultimately closes the loop on the “once they leave the hospital, how do you know that they were there and was the care delivered of value?” question.

“If you’re waiting for claims reconciliation to review data, you’re waiting too long,” Bruno says. The ability to impact the appropriate next setting needs to happen prior to discharge – waiting for retroactive claims results only allows you to improve in the future.

Set appropriate goals

If your goal is to lower readmission rates, look at the data that will inform your efforts accordingly. What targeted interventions can mitigate risk factors and reduce readmissions? How can you consistently achieve high performance in BPCI Advanced quality measures and in your composite quality score (CQS)?

“Get into the weeds: Go out to a skilled nursing facility and see what a discharge after 5 p.m. or on a weekend looks like,” says Dr. Mathew. From that real-time data and insight, you can set appropriate goals, such as ensuring all discharges are completed as early as possible and that the transitions become bi-directional with respect to handoff communication.

Engaging clinical staff with detailed data drives quality assurance forward and connects claims outcomes to value-based care goals. By looking at longer periods for an episode of care, your clinical staff can begin to understand how important it is to build a tight, collaborative network with PAC providers. It may also lead to more complete conversations regarding patient care, including questions about caregiver support and social determinants of health.

Find your “accountability champions”

Now that you’ve looked more closely at the data and determined the levers for success, how do you actually get to your goals?

Data provides accountability, by identifying your “accountability champions,” says Dr. Mathew. Who are your high-quality PAC providers? And how can you leverage them?

“The key to success is setting up networks and sharing data transparently,” he says. “By building these teams and establishing engagement early, expectations surrounding performance in a value-based environment becomes part of routine communication.”

What’s next?

The next milestone in BPCI Advanced falls on December 1 when participation agreements are due to CMS to decide whether applicants want to commit to participate in Model Year 3 starting on January 1, 2020. The window to review their data before committing to participant is shrinking. The time to get organized and dig deep into the data is now.


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