PatientPing + Appriss Health: Solving Care Collaboration Challenges to Transform Whole Person Care

By now, you have probably heard that Appriss Health acquired PatientPing. While we have discussed how this acquisition will improve whole-person care across America, this post expands on that. You can find the original version of it right here, on PatientPing’s website.

We recently announced that PatientPing is joining forces with Appriss Health. We believe that this combination will substantially improve how care is delivered in America—transforming whole-person care.

Why? PatientPing and Appriss Health share the same goal: enabling better care for patients across the physical and behavioral health continuum, improving health outcomes, and lowering the total cost of care. Together, we can help solve care collaboration challenges better and faster than anyone else.

The merger has created one of the largest and most diverse care collaboration networks in the country, connecting nearly one million healthcare professionals in all 50 states and virtually all care settings including primary and specialty care, emergency departments, urgent cares, inpatient facilities, skilled nursing facilities, post-acute facilities, behavioral health treatment centers, pharmacies, home health agencies and state health agencies, and social and human service agencies, among others. Our powerful network serves the largest hospital systems in the U.S., 43 state governments, every national pharmacy chain, the top eight payers, and 7,800 post-acute facilities.

This ultimately enables healthcare providers to better understand all of the issues that an individual is dealing with in order to prioritize and coordinate care plans so health outcomes are the best they can possibly be—no matter the provider or care setting.

What does this mean for you?

  • Healthcare providers will be able to see historical utilization across acute and post-acute care, flag high utilizers, review controlled substance utilization history with patients, flag substance use disorder risk, facilitate referrals to behavioral health and post-acute providers, and much more. This will help you to collaborate on shared patients across the spectrum of care, solving many of the problems caused by incomplete information and the inability to communicate with other care team members.
  • ACOs, health plans, and care management organizations will receive data on encounters from the largest, most diverse network of providers and be able to return actionable insights to point-of-care clinicians at virtually all care settings.  This helps to efficiently coordinate care in real-time, lowering the cost and improving the quality of care.
  • States will be equipped to take on public health challenges like never before, with the aggregated data and analysis needed to tackle issues such as the mental health crisis and opioid epidemic.
  • Pharmacies will be able to better understand the history of the patients they are serving and make better decisions about prescription dispensation.

In short, PatientPing and Appriss Health have created the first-of-its-kind national whole-person care coordination network, ultimately changing the patient-clinician experience at the point of care. This will be transformational—connecting providers across all care settings and geographies to work together to understand the challenges that both patients and providers are facing, improving clinical episodes and care transitions for the millions of patients that interact with the nation’s healthcare providers.

The Ever-Reaching Extent of America’s Mental Health Crisis—and Our Response

COVID-19 and other factors have increasingly compromised mental health in America, leading to an alarming crisis among our youth and a response from Bamboo Health.

According to a survey conducted by the Centers for Disease Control and Prevention (CDC) and the Census Bureau, over one-third of American adults are experiencing some symptoms of anxiety or depression—a three- to four-fold increase over 2019. The numbers are fairly consistent across demographics, with young adults affected most.

COVID has stifled young adults and children in numerous ways. First and foremost, it has prevented regular, in-person socialization, particularly in classrooms. Second, it—and the media’s justified, yet relentless coverage of it—has caused angst, especially in the malleable minds of our youth. This heightened level of stress can precipitate into anxiety, depression, or worse.

It is worth noting that COVID is not the only factor that has contributed to this crisis. It has been argued that other factors such as devalued parental care and lack of access to care have also played major roles.

Sadly, many hospitals across the country have realized a dramatic increase in emergency department (ED) visits related to mental health, triggering capacity issues and delaying proper care. At Wolfson’s Children Hospital in Jacksonville, FL, over two-dozen children have been boarded in rooms, awaiting open beds in the hospital’s inpatient psychiatric unit. In Colorado, Children’s Hospital Colorado has declared a state of emergency for pediatric mental health.

Mental health issues all too often go hand-in-hand with substance use disorder (SUD). In fact, according to the National Institute on Drug Abuse, roughly 60% of adolescents in SUD treatment programs can be diagnosed with mental illness, and vice versa.

The worst-case scenario for anyone suffering from mental health issues and/or SUD is suicide, and unfortunately, there are some ominous trends. The CDC has recognized an increase in attempted suicides by teenage girls; ED visits because of suspected suicides rose 51% for girls aged 12 to 17 from 2019 to 2020.

Bamboo Health’s Response to America’s Mental Health Crisis

As you may know, Bamboo Health acquired OpenBeds in late 2019. OpenBeds is a comprehensive behavioral health capacity management and referral technology solution. It is our goal to help states, health systems, and health plans provide access to care to at-risk consumers, combating the crisis and, in turn, improving public health.

Two years later, OpenBeds goes beyond capacity management and referrals, with two different tools developed in response to today’s mental health and SUD crisis.

Our Treatment Connection tool enables the public to seek treatment for themselves or their loved ones in our customer states, in a confidential manner. In each state, we facilitate a network of state-vetted providers who offer inpatient and outpatient services. Between visiting Treatment Connection and being connected to fitting treatment, there are just three steps: searching for treatment, learning about treatment, and expressing interest.

Our Crisis Management module has revamped the way people in crisis are rapidly connected to care. The module expedites access to assessment and treatment for those in crisis, tracks their journey from call to treatment, and coordinates all stakeholders within a crisis management system, including the Department of Behavioral Health and Developmental Services, law enforcement agencies, local community organizations, and hospitals and healthcare facilities. A direct link between crisis call center professionals and mobile crisis response teams—all in a user-friendly interface—offers faster responses and treatment.

As Dr. Nishi Rawat, OpenBeds’ Co-Founder and Bamboo Health Chief Medical Officer states, “Over the past year, we’ve been getting more and more requests… to support the end-to-end clinical crisis continuum… the demand for behavioral health services is unprecedented.”

Use Case Spotlight: How Eleanor Health utilizes Pings’ real-time ADT notifications to proactively and promptly engage members and coordinate care

Eleanor Health provides value-based substance use disorder (SUD) and behavioral health care management services to its 1,000+ community members in over 12 locations across six states: North Carolina, New Jersey, Massachusetts, Washington, Louisiana, and Ohio. Through medications for substance use disorder (MSUD), therapy, psychiatry, nurse care management, and community-based resources, Eleanor takes a whole-person approach that fosters long-term physical and mental health recovery. Eleanor’s suite of outpatient services meets the patient where they are through telehealth appointments, clinics, community settings, and field-based teams.

We sat down with Ben Hall, SVP, Head of Product Strategy and Alex Piersiak, Director of Marketing, Member Growth & Engagement from Eleanor to discuss how their team approaches care coordination in a value-based care world, challenges they face in this endeavor, and how Pings helps improve patient outcomes.

Appriss Health and PatientPing became Bamboo Health in 2021.

What are some of the care coordination initiatives your organization focuses on?

Ben: From day one, Eleanor Health has operated with a mission of treating the whole person, which innately requires the coordination of long-term care in a value-based setting. To succeed at this, we must collaborate with other health care providers like emergency departments, primary care physicians, and inpatient treatment providers. Effective care coordination helps us contribute to what we call a patient’s “recovery capital score,” which is more than just clinical outcomes; it includes their job security, living in a safe environment, and family involvement in their recovery. As a value-based care driven organization, we also take on financial risk at both the individual and population level to drive home our mission of helping people affected by addiction live amazing lives. 

Alex: Moreover, we like to refer to ourselves as a medical home that specializes in substance use disorder and mental health. So, it is not just our goal, but our purpose to address addiction, mental health, social determinants of health, and physical health in conjunction with the coordination amongst such efforts.

What challenges has your organization faced in succeeding under these initiatives?

Alex: Timeliness is key. Care coordination cannot happen properly without near real-time follow up because that determines the success of building relationships with our members as well as their engagement in their treatment and recovery journey. From events ranging from an emergency room discharge to something such as a patient’s birthday, it is key that that outreach happens within 48-72 hours in order to truly improve patient care and engagement. 

Ben: Plus, it is very time consuming, inefficient, and unproductive to have to work to connect to every hospital or HIE in each of our markets. To get that visibility and scale of a network, especially when you’re growing quickly and operating in multiple states like we are, it’s a non-starter to have to build those connections ourselves for care coordination purposes. We wanted to supplement what we get from our EHR’s connectivity across the nation with other networks that exist, and PatientPing is a one-stop-shop for it all.

How has PatientPing helped play a role in overcoming some of these challenges?

Ben: We luckily started using PatientPing early on in Eleanor’s life as an organization, but before PatientPing, we relied on self-reported medical histories, outcomes, and care events from our patients. The PatientPing platform has proven to us that members typically under report care events, but since PatientPing gives us real-time alerts, we are equipped with the knowledge and insight needed to best care for our patient population.

Alex: We have two teams at Eleanor that actively use PatientPing for different subsets of our member base, and the platform helps each team promptly engage with patients. One team receives Pings (PatientPing’s real-time notification system) for populations that our health plan partners attribute to us based on SUD risk factors or diagnoses, which allows them to proactively reach out and keep recovery services top of mind. That team also uses PatientPing to reach out after a care event to prospective members that were formerly interested in our services, but never fully engaged, in order to see if now is a good time to meet with us. The second team is our nurse care managers that monitor Pings for patients who had an appointment with us in the last 60 days, who we call active members. These Pings prompt the nurse care managers to conduct a wellness check to coordinate care with their primary care physician (PCP) or schedule a follow-up appointment with us if necessary.  

Additionally, PatientPing gives both teams the most up-to-date contact information, which can be hard for the population we serve since our patients may have housing instability or call from different phone numbers.  

Can you tell us about a time when PatientPing helped you to improve care for a member?

Ben: Our clinic manager received a Ping that one of our members had relapsed, and unfortunately this member had been unengaged in their care with Eleanor for some time. When our staff member reached out, the member told them that they weren’t going to let Eleanor know what happened because they felt ashamed, but they were so grateful that Eleanor reached out to check in. The member felt incredibly cared for and the best part is that this member reengaged in their care with us after we reached out!

The CMS E-Notifications CoP Compliance Breakdown: Large Hospitals and Health Systems

The Centers for Medicare and Medicaid Services’ (CMS) Interoperability and Patient Access E-Notifications Condition of Participation (CoP) deadline is rapidly approaching for hospitals and health systems. From the smallest rural hospitals to the largest health systems, compliance with this CoP brings varying levels of complexity. Large hospitals and health systems face a complex web of challenges – from facilitating workflow consistency to ensuring the quality of patient care and beyond. Variables like these, along with the looming deadline for achieving compliance with the CMS Interoperability and Patient Access Rule E-Notifications Condition of Participation Provision, as well as the pandemic, make for a complex situation, especially for CIOs and administrative professionals who often have more robust IT systems requiring added compliance and technical complexity than smaller hospitals.

Given the significance of the new e-notifications CoP, CIOs and compliance leaders should take time to carefully assess the new requirements to ensure they can meet compliance by May 1st. We’ve compiled a checklist of Q&A’s to help guide you through the process. These questions can be used as a resource to help clarify any misconceptions and provide advice for implementing a CoP solution that addresses the unique pain points that large hospitals and health systems deal with every day.

Does our existing relationship with our EHR vendors ensure 100% compliance with the e-notifications CoP?

EHRs have a critical role to play in enabling interoperability to support policy goals. However, like all software, EHRs are limited by their functional capabilities, adoption within and outside the provider community, and delivery/support model. Unlike the CMS Meaningful Use Program, there are no accompanying set of certification requirements or responsibilities imposed on the EHR (or for that matter, an HIE) in order to meet the e-notifications CoP requirements in the CMS Interoperability and Patient Access Rule. The responsibility is entirely on the shoulders of the health system. As such, it is important that health systems sufficiently evaluate the CoP support being developed by their EHRs to ensure that they successfully comply with this important rule.

Our organization is well-positioned to meet the majority of the compliance requirements. Do we really need to field all external requests for e-notifications from community providers?

For health systems with large provider and post-acute referral networks, hospitals must send e-notifications to community-based providers that have established care relationships with patients, including: primary care practitioners, FQHCs, other entities identified by the patient as primarily responsible for their care, and post-acute providers (skilled nursing facilities, home health agencies, etc.). This information is needed for treatment, care coordination, or quality improvement activities. Therefore, identifying which providers have established care relationships is critical and requires that hospitals, or their intermediary, possess the capabilities to collect patient-identified provider information at the point of care; and obtain care relationship information from providers through a patient roster and notification request process. The roster and notification request process allow providers to identify their care relationships through a roster, such as a patient panel or census list, and receive e-notifications based on hospital care events that match to patients on those rosters. Having these capabilities gives hospitals the ability to determine the required set of providers that need notifications, thereby eliminating e-notification gaps that would lead to non-compliance.

We have a large network of providers and access to a significant amount of electronic data. Is this combined with our HIE network enough to ensure 100% compliance with the e-notification CoP?

HIEs can help with e-notifications compliance, but the hospital is ultimately responsible for ensuring the intermediary it uses is a fully compliant solution. Depending on the HIE’s capabilities, post-acute network coverage, and the hospital’s own geographic reach, there might be gaps that need to be filled. Since most HIEs send notifications only within their state or regional borders, they may not have the required dynamic roster or census capabilities developed to service the full range of providers as required by the CoP. These types of limitations would prevent notifications from being sent in real time on behalf of the hospital to all providers that must receive them. With the ultimate burden of accountability falling on hospitals to meet compliance requirements even if they use an intermediary, it is important for hospitals to proactively assess the capabilities of their HIE in order to avoid non-compliance risk and undue exposure.

We don’t want another layer of technology to log into to send and receive data. Can we handle the requirements internally?

The new CoP promotes the adoption of a more comprehensive information sharing solution, which makes it an important step for improving care coordination efforts nationwide. In order to avoid deficiencies on surveys, hospitals must understand and address all requirements. Any gaps in notification sending and routing will need to be identified and hospital leaders must determine whether to address these gaps by building their own solution or by using an intermediary to supplement existing systems. Large hospitals and health systems setting up their own process for handling the requirements internally should plan for a moderate to significant increase in their operating budgets, as it will require a full assessment of current capabilities compared against the CoP requirements. To meet these requests, hospitals are required to manage patient rosters and match patient care events to those rosters, which then trigger notifications. This means that because care relationships can change daily, patient attribution information from rosters will also need to be updated accordingly, which can increase the technical complexity of managing e-notifications. Beyond this, hospitals will need to establish necessary data share agreements between the hospital and the notification recipient to ensure compliance with all federal and state laws and regulations. For large hospitals and health systems, it is also important to consider any updates to workflows, processes, and human resource requirements for establishing this type of infrastructure in order to determine if they can adequately be met. Many hospitals are finding that alternative solutions are often more cost effective and more easily integrated with existing technology – delivering more insight than a manual approach can provide.

The CMS E-Notifications CoP Compliance Breakdown: Small-Sized Hospitals

The Centers for Medicare and Medicaid Services’ (CMS) Interoperability and Patient Access E-Notifications Condition of Participation (CoP) deadline is rapidly approaching for hospitals and health systems. From the smallest rural hospitals to the largest health systems, compliance with this CoP brings varying levels of complexity. Apart from the CoP, small-sized hospitals face several unique challenges daily – whether it be limited physicians or more limited access to financing than larger institutions. Variables like these, combined with a global pandemic and looming deadline for achieving compliance with the new CMS CoP, make for a challenging scenario.

For CIOs and IT professionals working in a small-sized hospital, who often lack the compliance and technical support of larger hospital systems, the time to prepare is now. It is critical for small-sized hospitals to understand the intricacies of the new rule and adjust their practices accordingly to ensure 100% compliance with the e-notifications CoP. Below is a list of common Q&A’s to consider when assessing what, if any, changes your hospital needs to make. These questions can be used as a resource to help clarify any misconceptions and provide advice for implementing a CoP solution that addresses the unique pain points that small hospitals deal with every day.

Does my hospital’s existing relationship with our EHR vendor ensure 100% compliance with the e-notifications CoP?

While most EHR vendors typically provide solutions to enable Direct Messages upon inpatient events, in particular discharge events, as was specified under Meaningful Use, the new CoP notification requirements are expanded where hospitals must send notifications upon all inpatient and emergency department events. Furthermore, those notifications must not only be sent to providers identified in the EHR but also to those providers with attributed patients that request notifications to support treatment and care coordination activities. To do so, solutions need three key components: 1) manage notification requests from patients’ attributed providers across the care continuum, 2) accurately match patients’ care events, and 3) send notifications based on the matches in real-time to the appropriate practitioner or entity. Any hospital that aims to rely on its EHR vendor to meet compliance requirements should assess whether the vendor can indeed offer a complete solution and how it might guarantee compliance.

Most of our patients are local. Is our HIE able to ensure 100% compliance with the e-notification CoP?

The CoP requires e-notifications be sent at the time a patient event occurs to any established practitioner, practice group/entity, or post-acute regardless of their geographic location. While most care events in your smaller system may be local, the CoP requires that your hospital account for all scenarios to ensure care coordination both within your system and beyond so you must account for scenarios such as a patient traveling across state lines. Since most HIEs send notifications only within their state or regional borders, they may not have the required dynamic roster or census capabilities developed to service in the full range of providers as required by the CoP. Such limitations would prevent notifications to be sent in real time on behalf of the hospital to all providers that must receive them. Since hospitals will be ultimately held accountable for meeting compliance requirements even if they use an intermediary, hospital leaders should evaluate their HIE’s capabilities and assess if they might face non-compliance risk and undue exposure. As a small hospital system, we’re looking to save costs as much as possible.

What kind of increase can our hospital expect to see in our operating budgets by setting up this process?

Can we handle the requirements internally? The CoP intends for hospitals to adopt a more comprehensive information sharing solution, so hospitals must understand and address all requirements to avoid deficiencies on surveys. Hospitals planning to set up a process to handle the requirements internally will need to plan for a moderate to a significant increase in their operating budgets, as it will require a full assessment of their current capabilities compared against the CoP requirements. Meeting these requests will require hospitals to manage patient rosters and match patient care events to those rosters, which then trigger notifications. Because care relationships can change daily, especially in the post-acute setting, patient attribution information from rosters will also need to be updated accordingly, which can increase the technical complexity of managing e-notifications. In addition, any necessary data share agreements need to be in place between the hospital and the notification recipient to ensure compliance with all federal and state laws and regulations. Hospitals should consider the workflows, processes and human resource requirements for establishing this type of infrastructure to determine if they can adequately address them. In most cases, an alternative solution can be more cost-effective and provide more insight than implementing a manual approach.

We can afford to take on more risk than a larger hospital system, so why do we need to prioritize this requirement now?

Every hospital from small to large is governed by this rule, so the necessary data share agreements need to be in place between the hospital and the notification recipient to ensure compliance with all federal and state laws and regulations. Given the significant consequences of non-compliance, hospitals of all sizes need to assess their existing notification capabilities and identify any gaps as quickly as possible as building a solution or vetting a third-party intermediary will require time. As the May 1, 2021 compliance deadline approaches, hospitals need to consider the workflows and processes they have in place to meet these requirements and whether they can adequately address them.

The CMS E-Notifications CoP Compliance Breakdown: Mid-Sized Hospitals

The Centers for Medicare and Medicaid Services’ (CMS) Interoperability and Patient Access E-Notifications Condition of Participation (CoP) deadline is rapidly approaching for hospitals and health systems. From the smallest rural hospitals to the largest health systems, compliance with this CoP brings varying levels of complexity.

Today’s mid-sized hospitals can face their own set of challenges ranging from the increased demand for service lines, growing patient populations, and the need to share data with regional health exchanges while complying with expanding regulatory requirements. Considerations like these, combined with the COVID-19 pandemic and impending deadline for achieving compliance with the CMS Interoperability and Patient Access Rule E-Notifications Condition of Participation Provision, make for an overwhelming task, especially for CIOs and administrative professionals who typically have more complicated systems than small hospitals, with fewer compliance and technical support staff than larger hospital systems.

With the May 1st deadline rapidly approaching, we’ve compiled a list of Q&As to help guide you through the process. These questions can be used as a resource to help clarify any misconceptions, avoid deficiencies that could jeopardize your CMS certification status, and provide advice for implementing a CoP solution that addresses the unique pain points that mid-sized hospitals face on a daily basis.

As a mid-sized hospital, we have a large local network of providers. Is our HIE able to ensure 100% compliance with the e-notification CoP?

Even though most care events in your mid-sized hospital network may be local, the new CoP requires e-notifications be sent at the time a patient event occurs to any established practitioner, practice group/ entity, or post-acute regardless of their geographic location. This means that your mid-sized hospital must ensure care coordination both within your system and beyond, which requires the consideration of scenarios such as a patient traveling across state lines. Because most HIEs send notifications only within their state or regional borders, they may not have the required dynamic roster or census capabilities developed to service in the full range of providers as required. Limitations such as these would prevent real-time notifications from being sent on behalf of the hospital to all necessary providers. As a result, it is critical for hospitals to evaluate your HIE’s capabilities in order to avoid non-compliance risk and undue exposure, as even if you use an intermediary, hospital leaders are ultimately held accountable for meeting compliance requirements.

Our mid-sized hospital already has an existing relationship with EHR vendor(s). Do we already have the capabilities to field all external requests for e-notifications from community providers?

Most EHR vendors typically provide solutions to enable Direct Messages upon inpatient events, in particular discharge events, as was specified under Meaningful Use. However, the new CoP notification requirements are expanded where hospitals are required to send notifications upon all inpatient and emergency department events. To support treatment and care coordination activities, this rule expansion also makes it so those notifications must be sent to providers identified in the EHR as well as to those providers with attributed patients that request notifications. As a result, your hospital’s solution must: 1) manage notification requests from patients’ attributed providers across the care continuum, 2) accurately match patients’ care events, and 3) send notifications based on the matches in real-time to the appropriate practitioner or entity. This means that it is most likely not enough to rely on your EHR vendor to meet compliance requirements. You can assess this by approaching your EHR vendor directly. Ask them if your existing EHR solution has the ability to guarantee compliance with the new rule.

We don’t want another layer of technology to log into to send and receive data. Can we handle the requirements internally?

The ultimate goal of the new CoP is for hospitals to adopt a more comprehensive information sharing solution. As a result, it is critical for mid-sized hospitals to fully understand and address all requirements in order to avoid deficiencies on surveys. Hospitals should plan for a moderate to significant increase in their operating budgets if they wish to establish a process to handle the requirements internally because it will require a full assessment of current capabilities compared against the requirements of the CoP. To meet CoP requests, your hospital will need to have the capability to manage patient rosters and match patient care events to those rosters, which then trigger notifications. Also, since care relationships can change daily, your mid-sized hospital will need to plan for an increase in the technical complexity of managing e-notifications as your patient attribution information must be updated from rosters accordingly. To determine if your hospital can adequately address the requirements, you will need to consider the added workflows, processes and staffing requirements for establishing this type of infrastructure, as well as account for any necessary data share agreements between the hospital and the notification recipient to ensure compliance with all federal and state laws and regulations. Due to this level of complexity, many mid-sized hospitals are finding that an alternative solution can be more easily integrated with existing technology and is often more cost effective to implement a manual approach.

Amidst COVID-19 and other initiatives, our hospital has a lot going on. Do we need to prioritize this requirement right now?

Necessary data share agreements need to be in place between the hospital and the notification recipient to ensure compliance with all federal and state laws and regulations. As a result, hospitals of all sizes need to assess their existing notification capabilities and identify any gaps as quickly as possible, as building a solution or vetting a third-party intermediary will require time, and there will be significant consequences of non-compliance. Mid-sized hospitals assessing their priorities should consider the workflows and processes they have in place to meet these requirements and whether they can adequately address them in time for the May 1st compliance deadline.

BPCI-Advanced: Unpacking the Model Year 4 Changes

The Bundled Payments for Care Improvement Advanced Model (BPCI-Advanced) is a voluntary advanced alternative payment model that began in October of 2018, and is set to continue through 2023. The model serves Medicare fee-for-service (FFS) beneficiaries and allows participants to take on risk for the 90-day duration of up to 31 eligible inpatient clinical episodes and 4 eligible outpatient clinical episodes. Total Medicare FFS expenditures for the 90-day clinical episodes are reconciled against Target Prices, enabling participants to receive a single retrospective payment for their attributed clinical episodes, with payment reconciliation done on a semi-annual basis.

In September of 2020, the Centers of Medicare and Medicaid Services (CMS) released updates to Model Year 4 of BPCI-Advanced, which went into effect in January of 2021. The model changes were designed to help ensure the program achieves its goal of providing Medicare savings without sacrificing patient care quality. The changes will mitigate participant clinical episode selection bias, improve Target Price accuracy, and help CMS ensure reconciliation payments are made as a result of true cost reductions versus participant regression to the mean.

Below is a breakdown of the five major changes made by CMS to Model Year 4, and the impact these changes will have on BPCI-Advanced participants.

Change #1: Clinical Episode Service Line Groups (CESLGs)

The first major change to Model Year 4 is the creation of clinical episode service line groups. With this new change, the 35 BPCI-Advanced clinical episodes are bucketed into 8 clinical episode service line groups; cardiac care, cardiac procedures, gastrointestinal surgery, gastrointestinal care, neurological care, medical and critical care, spinal procedures, and orthopedics.

With this change, participants are now required to select clinical episode service line groups and must participate in all the clinical episodes within each grouping unless they do not meet the minimum volume threshold for any component clinical episode during the baseline period. Additionally,  participation in clinical episode service line groups will be locked in for three years, meaning participants cannot drop these groupings and still remain in the program.

Change #2: New Clinical Episode Overlap Methodology

The second major model change is the introduction of a new clinical episode overlap exclusion methodology. In Model Year 4, CMS is excluding any clinical episodes that would have been normally triggered while a beneficiary has an ongoing separate clinical episode. This in effect means that no BPCI-Advanced clinical episodes will be overlapping. It is important to note that overlapping clinical episodes will be excluded regardless of whether the initial ongoing episode was attributed to a BPCI-Advanced participant or not.

Change #3: Realized Peer Group Trend Adjustment

The third major change to Model Year 4 is the introduction of a retrospective peer ground trend adjustment. With the new update, CMS will adjust final Target Prices at Reconciliation for peer group trends found in Performance Period Clinical Episodes spending. This means that CMS will cap the difference between the realized retrospective peer-group trend factor from the preliminary prospective peer-group trend factor at 10% of the preliminary prospective trend. Peer groups are based on relevant hospital characteristics, such as region, size, academic medical center status, safety net status, and urban versus rural status.

Change #4: Removal of Physician Group Practice (PGP) Offset

The fourth major model change in Model Year 4 is that CMS will remove the PGP offset used in PGP target price construction. This means that each clinical episode category will have a single target price that does not vary irrespective of the individual PGP that triggered the episode.

This change will create the same Target Prices for PGPs as acute care hospitals (ACHs), except for their respective patient Case Mix Adjustments (CMA), simplifying the program’s pricing methodology and easily allowing for program scale. In terms of participant impact, this change could lead to possible increases in savings for historically efficient PGPs and a possible reduction in savings for historically inefficient PGPs.

Change #5:  Major Joint Replacement of the Lower Extremities Risk Adjustment

The final major program change is that CMS will add procedure flags to the Model Year 4 risk adjustment model for the Major Joint Replacement of Lower Extremities (MJRLE) clinical episode. This includes flags for; partial knee arthroplasty, total knee arthroplasty, partial hip arthroplasty, total hip arthroplasty and hip resurfacing, ankle and reattachments, and others. CMS will use these flags to improve the precision of the MJRLE clinical episode category risk adjustment and Target Prices.

In light of these recent changes, BPCI-Advanced participants should keep in mind two key considerations; the requirement of rapid financial assessments and decision making, and the likelihood that CMS will introduce mandatory bundled payment programs after the initial program conclusion in 2023. To help ensure they meet their programs’ clinical and financial goals, participating organizations should incorporate proper workflows and supporting infrastructures, and prepare for the future mandatory bundled payments value-based care programs that are to come.