Another essential attribute for success involves the level of physician engagement. Assessing which clinical areas have strong physician champions or leaders is a great first step in understanding your level of physician engagement. To enhance physician engagement, organizations should focus on active change management combined with thoughtful gainsharing models. Communication and transparency regarding performance and potential gainsharing also influences engagement for ongoing performance improvement.

DC: We’ve also found volume of episodes to be important as well. There is no single “right” volume threshold, but understanding where the proper balance is helps minimize the risk of outliers. For example, hospitals which are Episode Initiators must have 41 or more episodes in the four-year baseline period to be eligible to participate in a clinical episode. This translates to 10 episodes per year, which is very low. While organizations may think such low-volume bundles provide a safe transition into value-based care, we have found them to be very volatile. That said, one or two well-performing episodes can offset small losses in other episodes for an overall savings. Of course, this means that the opposite can also happen – small gains over most episodes can be wiped out by a large loss on just a single episode.


Finally, episode type is important because not all episodes are created equal. For instance, lower and upper extremity joint replacement episodes are mostly elective, while percutaneous coronary intervention is a mixture of elective and emergent. And then there are surgical fixation of hip/femur fractures, which are all urgent or emergent. Furthermore, some episodes are medical, and some are procedural. Each of these “types” has advantages and disadvantages.

HCB News: How many different bundles or clinical episodes should organizations pursue?
DC: There isn’t an exact or right number’ instead, selection should be tailored to each organization based on their level of experience and existing capabilities. We encourage organizations to start with a few prioritized bundles where they are most set up for success and which best align with their strengths. Additional bundles can be added once an organization has built foundational capabilities. CMS has already announced that BPCI-Advanced will accept a second cohort starting on January 1, 2020. Therefore, organizations should take this initial 15-month period to build those capabilities on a few initial prioritized bundles, and consider expanding with the second cohort.

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