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Three Successful Approaches to Gainsharing in Bundles

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Nearly 1,300 participants have chosen to remain in the Bundled Payments for Care Improvement (BPCI) Advanced program and the application period for the program’s next phase is quickly approaching. At the same time, providers across the nation are achieving success in bundled payments across the board.

In fact, organizations participating in Premier’s Bundled Payment Collaborative significantly outperform their peers in Medicare bundled payment programs, and the vast majority of them chose to stay the course with BPCI Advanced. Behind these efforts are successful gainsharing initiatives between physician practices and the health system that align performance improvement goals between organizations and their engaged physicians.

Because BPCI Advanced is the latest voluntary bundled payment program, providers are more knowledgeable about the opportunities to share savings than ever before. Today, participants in BPCI Advanced know which clinical episodes they should stick with long-term and many have engaged in efforts to incentivize performance with their physicians and post-acute providers through gainsharing. And while gainsharing (called Net Payment Reconciliation Amount (NPRA) Sharing in BPCI Advanced) isn’t as new of a concept as it was five years ago, physicians understand the potential and are keen to know the opportunities that exist for them – meaning they are upping the pressure on hospitals to gainshare.

For those participating or those that plan to participate in BPCI Advanced, now is the time to engage with physicians and post-acute care providers who deliver high-quality care and can help organizations achieve savings in the model.

Here are three successful approaches to getting started.

1. Get cozy with the rules

The episode attribution rules in the program allow physicians (attending and operating) to take precedence over hospital participants. As a hospital, engaging physicians for gainsharing now may mean your organization keeps the episode volume while still providing the desirable financial incentives to providers. However, gainsharing is a slightly different world today than in prior Medicare bundled payment programs, and understanding how to use these rules advantageously will be key to success.

For example:

  • There is no 50 percent professional fee cap. Although the full details haven’t been revealed, the Centers for Medicare & Medicaid Services (CMS) has communicated that it intends to eliminate the cap on gainsharing distributions that used to be limited to 50 percent of the providers’ professional fees on episodes to which they were attributed.
  • In other former and current bundled payment programs, organizations could use two funding sources for gainsharing – program savings (NPRA) and Internal Cost Savings (ICS). Although it’s still true in BPCI Advanced, additional requirements and stipulations are being imposed for ICS. For example, ICS can only be used as a funding source for gainsharing if the ICS results directly from care redesign efforts from gainsharers. This adds a layer of administrative complexity to using ICS as a gainsharing funding source.

2. Consider specialty areas

It’s important to take time considering which specialties will work best with an organization’s bundle patients and which may have the biggest impact of episode cost. This requires exploring which physicians interact with patients most often and have the most influence over their care. Sometimes this is clear cut, such as a surgeon for a procedural bundle. But bundles get muddier when a variety of different specialists support the patient mix.

Additionally, more hospital participants are in medical/non-procedural bundles than in the prior voluntary BPCI program. This means gainsharing may not occur with only one specialty as is normally done with procedural bundles (i.e., gainsharing with orthopedic surgeons in a joint replacement bundle).

Consider deploying a ‘team based’ gainsharing program that allows the organization to gainshare with multiple specialties at once. This brings key players to the table and allows providers to maximize their alignment efforts.

3. Use claims data

To make educated decisions on the performance measures gainsharers should be held to, use baseline data and the first few months of claims data from Medicare to understand patterns in post-acute care utilization and provider trends.

Involving physicians and post-acute care providers in care redesign efforts now will help to get their buy-in to promote better, more cohesive patient care in the future. As such, physicians will be more educated on performance metrics as well as overall episodic costs that will be part of the organization’s evolution toward change.

Gainsharing is a significant and powerful way for risk-bearing entities to entice better provider performance and fuel success in a bundled payment program. To learn more about the capabilities needed to succeed in BPCI Advanced, check out Ready, Risk, Reward: Keys to Success in Bundled Payments.

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