Tough decisions: How OCM and BPCIA participants managed COVID-19 overlap challenges

DATE: 11/10/2020

The COVID-19 pandemic has impacted every aspect of our healthcare system. That’s true for participants in the Oncology Care Model and Bundled Payments for Care Improvement Advanced programs. Organizations in these programs had to make important decisions regarding the overlap of their program performance periods with the COVID-19 public health emergency.

Several trends have begun to emerge from these choices. Here’s what DataGen’s analysts have seen from the data:


For performance periods that overlapped with the PHE, BPCIA participants had to decide if they would remove all upside and downside risk, or just remove COVID-19 patients from their reconciliation. From our analysis, it appears that decisions were balanced between these two options. We are not aware of any episode initiators who chose to continue their reconciliations as usual with no exclusions at all. Here’s what we believe drove those decisions:

  • Opting out of the performance period reconciliation entirely by removing all upside and downside risk was a safe bet. This was especially true for episode initiators who had a good deal of uncertainty about their BPCIA financials during the PHE. Since all episodes were impacted by the PHE, participants who chose this option are still facing potential financial losses internally.
  • Participants who had positive momentum in BPCIA were attracted to the option to carve out COVID-19 episodes from their reconciliation. Characteristics of participants who considered this option include: not being at risk for clinical episode categories mainly composed of elective procedures, being located in regions less impacted by the PHE and having already implemented noticeable practice transformation to project savings at least among the non-COVID-19 episode population.
  • Going forward as usual with the reconciliation — including all episodes and not carving out COVID-19 patients — required a significant level of confidence in the outcome of the performance period. It’s not surprising that this option wasn’t chosen.

Participants won’t be burdened with this choice moving forward. If the PHE continues and overlaps into model year 4, episodes for COVID-19 patients will be excluded from the reconciliation for all episode initiators.


For OCM, we saw strong alignment between the level of risk taken on by participants and how they would handle the overlap between performance periods and the PHE. Participants taking on one-sided risk tended to stay in the reconciliation with COVID-19 episodes carved out. This allowed them the opportunity to still earn a performance-based payment. Participants with two-sided risk tended to opt out of the reconciliation entirely to avoid any potential repayments to CMS in the impacted performance periods.

Regardless of those choices, most practices have signed the participation agreement to continue their OCM participation into calendar year 2021 for the two newly added performance periods. These additional periods will help practices continue the work they’ve undertaken to transform their oncology practices while getting the benefit of monthly enhanced oncology services payments to help fund that effort.

We have seen, however, that some practices at two-sided risk are still carefully weighing their options and right to terminate from the program before the next performance period start date. This decision-making process will likely be influenced by whether or not the PHE is extended — which would extend COVID-19 flexibilities. The most recent extension of the PHE will overlap with the start of the next performance period.

The pandemic has had many rippling effects on policy and programmatic changes for alternative payment models. While these changes have given participants flexibility to stay in the programs without risking an undue amount, it will be interesting to see what further changes, if any, happen if the PHE continues to be extended.

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