For example, if the group has chosen heart failure as an episode in which to participate at the program’s outset, a hospitalization is assigned the heart failure DRG (diagnosis-related group) and a group member is the Attending Provider on the claim form (and submits a claim for the physician services), then the episode is attributed to that group. This means that the group is responsible for payments represented by Medicare Part A and Part B claims (with a few exclusions like trauma and cancer) against the target price for the initial hospitalization and subsequent 90-day period. In practice, hospitalists are rewarded for actions aimed at optimizing location after discharge,4 avoiding readmissions, choosing efficient nursing facilities, and helping patients to maximize functional status.
The other way hospitalists may participate is through an agreement to share in savings with a hospital or physician group episode initiator. This requires hospitalist individuals or groups to enter into a contract with the initiator that meets certain program requirements – for example, report quality measures, engage in care redesign, use certified EHR technology (hospital-based clinicians automatically fulfill this criterion).
If there is broad participation, BPCI Advanced could represent a key milestone for hospitalists, as they seek to be recognized for the value they confer to the system as a whole instead of simply their professional billings. While there are legitimate concerns about the effect MIPS may have on health care value and the complexity of participation in APMs, barring a repeal of the law that created them, hospitalists now have the chance to extend their influence within and outside the hospital’s four walls and be more fairly rewarded for it.
Dr. Whitcomb is chief medical officer at Remedy Partners in Darien, Conn., and cofounder and past president of the Society of Hospital Medicine. Contact him at [email protected]. Disclosure: The author’s employer, Remedy Partners, is an Awardee Convener for the BPCI initiative and intends to apply as a Convener in BPCI Advanced.