BPCI Advanced CMS Voluntary Bundled Payment Program: Overview May 2019 - Date - Tower Health
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BPCI Advanced Date CMS Voluntary Bundled Payment Program: Overview May 2019 CONFIDENTIAL
Table of Contents
I. Introduction
II. Program Details
III. Strategic Considerations
Appendix A: Episode Detail
Appendix B: Target Price Detail
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 1I. Introduction CONFIDENTIAL 1678.010\480360(pptx)-E2 DD 5-7-19 2
I. Introduction
BPCI Advanced
CMS recently announced that it would be opening up its second application period
for BPCI Advanced in April, for a program start date of January 1, 2020.
ECG’s introduction to BPCI Advanced includes:
Description of program features, important
Program
application deadlines and other dates, clinical
Details episodes, pricing structure, and additional details
Strategic Strategic considerations regarding next steps,
Considerations staffing models, and other ECG recommendations
Note: Prospective Payment System–exempt cancer hospitals, inpatient (IP) psychiatric facilities, critical access hospitals, hospitals in Maryland, hospitals participating in the Rural
Community Hospital Demonstration, and participant hospitals in the Pennsylvania Rural Health Model cannot participate in BPCI Advanced.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 3I. Introduction
Current Participation
1,295 Participants 715 Acute Care Hospitals 580 Physician Group Practices
(ACHs) (PGPs)
Participation by Service Line
534
Kidney 479
Neurology 4% 469
4% 434
Gastrointestinal 371
(GI) 359
354
8% 353
345
Spine, Bone, 344
and Joint 344
Pulmonary 31% 315
10% 313
260
Infectious 235
Disease 232
13% 221
218
Cardiovascular 206
30% 198
189
184
165
143
111
100
93
70
63
Source: https://www.innovation.cms.gov/initiatives/bpci-advanced.
On March 1, 2019, 16% of participants
(295 providers) dropped out of BPCI Advanced.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 4I. Introduction
Program Benefits
Offers an opportunity to
learn how to manage
Qualifies as an total cost of care
Advanced APM;
physicians eligible for
bonuses under MACRA
Fosters a collaborative
BPCI clinical culture across
settings and functional
Engages and aligns Advanced areas
physicians and provides
certain gainsharing
waivers
Provides historical
benchmark data for Reduces costs and
episodes, within and improves care delivery
outside the organization across the episode
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 5II. Program Details CONFIDENTIAL 1678.010\480360(pptx)-E2 DD 5-7-19 6
II. Program Details
BPCI Advanced Overview
Program Features Key Stakeholders Eligible Participants
» BPCI Advanced is a voluntary bundled » Convener Participants bring together » ACHs and PGPs may take part as Convener
payment model with a single risk track. multiple downstream entities and facilitate or Non-Convener Participants.
» It includes 33 IP episodes and 4 outpatient coordination; they bear and apportion » Other entities may take part as Convener
(OP) episodes.1 financial risk. Participants only.
» The program runs from January 1, 2020, » Non-Convener Participants bear financial
through December 31, 2023. risk only for themselves, not on behalf of
multiple downstream entities.
» It qualifies as an Advanced APM.
Reconciliation and
Target Price Quality Measures
Payment
» A single retrospective payment includes a » A 3% discount is applied to historical » Participants can choose between two
triggering IP stay or OP procedure and the Medicare FFS expenditures for each quality measures sets: (1) claims-based
90-day period starting on the day of episode.2 measures used in MYs 1 and 2 including
discharge. » Preliminary TPs will be provided for each advance care plan, all-cause readmissions,
» The total Medicare fee-for-service (FFS) episode in advance of the first and other episode-specific metrics, or
payment for the episode is reconciled against performance period of each MY. (2) claims- and registry-based measures yet
target prices (TPs) on a semiannual basis to be defined.
and adjusted for quality performance. » Participants will be accountable for no more
than five measures per episode.
1 Participants that start in Model Year (MY) 3 (January 1, 2020) may not add or drop clinical episodes until the start of MY 4 (January 1, 2021). Active participants as of March 2019 will not
be allowed to make any changes until the start of MY 3 (January 1, 2020).
2 The 3% discount is a continuation from MYs 1 and 2. However, CMS may make slight adjustments to this amount in future MYs.
Source: https://www.innovation.cms.gov/initiatives/bpci-advanced.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 7II. Program Details
Clinical Episodes
Starting Model Year 3, there are a total of 37 clinical episodes (4 outpatient and 33
inpatient). New episodes for 2020 are indicated in bold font.
Cardiovascular Spine, Bone, and Joint Gastrointestinal
» Acute myocardial infarction » Back and neck except spinal fusion (OP » Disorders of the liver (excluding
» Cardiac arrhythmia episode) malignancy, cirrhosis, and alcoholic
» Cardiac defibrillator (OP episode) » Cervical spinal fusion hepatitis)
» Cardiac valve » Combined anterior posterior spinal » GI hemorrhage
» Congestive heart failure (CHF) fusion » GI obstruction
» Coronary artery bypass graft » Double joint replacement of the lower » Inflammatory bowel disease1
extremity » Major bowel procedure
» Pacemaker
» Fractures of the femur and hip or pelvis
» Percutaneous coronary intervention
(PCI) (OP episode) » Hip and femur procedures except major Neurology
joint
» Transcatheter aortic valve » Seizures1
replacement (TAVR)1 » Lower extremity/humerus procedure
except hip, foot, and femur » Stroke
Kidney » Major joint replacement of the lower
extremity (IP and OP1 episodes)
Pulmonary
» Renal failure
» Major joint replacement of the upper » Chronic obstructive pulmonary disease
extremity (COPD), bronchitis, asthma
Infectious Disease » Spinal fusion (noncervical) » Simple pneumonia
» Cellulitis
» Sepsis Bariatrics
» Urinary tract infection (UTI) » Bariatric surgery1
1 New clinical episode for MY 3.
Source: https://www.innovation.cms.gov/initiatives/bpci-advanced.
Note: Participants that start in MY 3 (January 1, 2020) may not add or drop clinical episodes until the start of MY 4 (January 1, 2021). Active participants as of March 2019 will not be allowed
to make any changes until the start of MY 3 (January 1, 2020).
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 9II. Program Details
Timeline
November 2019
» CMS Selects Second
October 1, 2018 Cohort
BPCI Advanced June 24, 2019 » Participation Agreements January 1, 2020
Starts for First Deadline: Applications and Participant Profiles BPCI Advanced Starts
Cohort Are Due to CMS Are Due for Second Cohort
April 24, 2019 September 2019 December 2019
Application for » Historical Claims and Submit All Other
Second Cohort TPs Are Distributed to Q1 2020
Begins Applicants Deliverables to
» CMS Distributes CMS
Participation Agreements
The BPCI Advanced program ends for both
cohorts on December 31, 2023.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 9II. Program Details
Exclusions and Precedence Rules
A Medicare FFS beneficiary receives an anchor service for a BPCI
Advanced clinical episode at a participating acute care hospital.
Is the beneficiary Is the anchor Is the Is the
aligned to: service a joint attending operating
» A Next Generation replacement, physician part physician part The clinical
Accountable Care and was it of a PGP of a PGP episode is
Organization (ACO)? No performed at a No participating in No participating in No
attributed to
» Medicare Shared Comprehensive BPCI BPCI the ACH.
Savings Program Care for Joint Advanced? Advanced?
ACO Track 3? Replacement
» An ESRD Seamless (CJR) hospital?
Care Organization with
downside risk? Yes Yes Yes
» An ACO participating in
the Vermont Medicare The clinical
ACO Initiative? The clinical The clinical
episode is
episode is episode is
Yes
excluded and
attributed to the attributed to the
attributed1 to the
PGP. PGP.
CJR hospital.
The clinical
episode is
excluded.
1 Attributed to the entity that is at risk.
Source: https://www.innovation.cms.gov/initiatives/bpci-advanced.
Note: CMS has not released details regarding the overlap between BPCI Advanced and Pathways to Success models. Entities may participate in both BPCI Advanced and the Oncology Care
Model; however, CMS will adjust Oncology Care Model payments based on episode overlap.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 10II. Program Details
Target Price
To determine program savings, CMS will compare Medicare FFS expenditures in
the clinical episode against the TP for that episode. Preliminary TPs will be
provided in advance of the first performance period of each MY.
Standardized
Patient Case Mix Peer-Adjusted
Baseline Spending
Adjustment (PCMA) Trend Factor
(SBS)
Historical efficiency of Adjusts for varying levels Adjusts for persistent Benchmark
ACHs based on risk- of severity1 in ACHs’ differences in episode Price
and peer-standardized patient case mix that are spending levels across
episode spending in the outside their control ACH peer groups2
baseline period
Benchmark 3%
TP
Price Discount3
1 Patient characteristic categories used to adjust risk include Hierarchical Condition Categories (HCCs), HCC interactions, HCC severity, recent resource use, demographics, long-term
institutional, Medicare Severity Diagnosis Related Group (MS-DRG)/Ambulatory Payment Classification (APC), comprehensive APC (C-APC), and clinical episode category–specific
adjustments.
2 Peer groups will be determined by geographical and hospital characteristics, including classifications such as academic medical center, urban/rural, safety net hospital, census division,
and bed count.
3 The 3% discount is a continuation from MYs 1 and 2. However, CMS may make slight adjustments to this amount in future MYs.
Source: https://www.innovation.cms.gov/initiatives/bpci-advanced.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 11II. Program Details
Reconciliation and Stop-Gain/Loss
CMS will apply a 20% stop-gain/loss provision to the net payment reconciliation
amount (NPRA); a participant may only earn up to 20% of its target spending if
savings are achieved.
Example: Stop-Gain Applied to Total Savings (NPRA)
Spending across All Episodes The difference Target Spend: $1,000,000
$1,200,000 between the target
spend and the Actual Spend: (750,000)
$1,000,000 actual spend is Savings/NPRA: $ 250,000
known as the
$1,000,000
NPRA. In this Quality Adjustment: (25,000)
$800,000
example, the NPRA (+/- 10%) $ 225,000
$750,000
is $250,000 across
$600,000
all episodes. This Stop-Gain
amount is adjusted (20% of Target Spend): $ 200,000
$400,000 for (1) quality
performance, up to The participant earns the lesser of the
$200,000 10%, and (2) a stop-gain or the quality-adjusted NPRA.
stop-gain provision. Net Program Earnings: $ 200,000
$0
Target Spending Actual Expenditures
(determined by CMS) (FFS)
Source: https://www.innovation.cms.gov/initiatives/bpci-advanced.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 12II. Program Details
Waivers
Payment Policy Waivers
If the participant wishes to furnish services to BPCI Advanced beneficiaries pursuant to the policy waivers
below, the participant must submit to CMS its intent to use the waivers in its Participant Profile.
Three-Day » Waives: Three-day rule for SNFs with overall rating of three stars or better
SNF Rule » Implications: Beneficiaries who meet clinical criteria discharged to a more
Payment appropriate care setting earlier (must enter into a written agreement with a
Policy Waiver qualified SNF to qualify)
Postdischarge » Waives: Direct supervision requirement
Home Visits
Payment » Implications: In-home postdischarge visits from a nurse without a physician
Policy Waiver present
Telehealth Payment » Waives: Geographic and originating site requirements
Policy Waiver » Implications: Delivery of telehealth services to beneficiaries in their homes
Source: https://www.innovation.cms.gov/initiatives/bpci-advanced.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 13III. Strategic Considerations CONFIDENTIAL 1678.010\480360(pptx)-E2 DD 5-7-19 14
III. Strategic Considerations
Key Resources
Preliminary discussions with select team members will help to frame initial
responses for each application question.
Quality Case Management
Care Coordination Finance
Legal and Compliance Strategy
Data and IT Medical Affairs
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 15III. Strategic Considerations
Key Questions
As organizations analyze their historical claims data and preliminary TPs, they should
keep in mind these considerations when determining which episodes to select.
Financial
Is the volume in the selected episode(s) sufficient?
How do readmissions and/or post-acute utilization rates drive cost in the episode?
How does episode cost compare to the TP? Will there be a savings opportunity?
Strategic
What is the organization’s appetite for moving from volume to value? Is the organization ready for value-
based payments?
Would the organization benefit from enhanced physician alignment through an initiative focused on
gainsharing of the savings associated with bundled payments?
Are there service lines that may benefit from additional efforts to either develop care pathways or further
refine and operationalize existing pathways?
Would the organization benefit from a more aligned and preferred post-acute care provider network?
Operational
What type of organizational and governance structures would need to be implemented to effectively
manage the bundled payment program?
Does the hospital have the appropriate administrative and physician leadership and support?
What type of analytics and performance reporting capabilities exist?
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 16III. Strategic Considerations
Episode Selection Analytics
ECG provides detailed analysis by episode in order to determine the participant’s greatest
opportunity for program success. A blinded client example in the first BPCI Advanced
cohort is shown below.
Average Average Variance Average Average PAC Cost
Average Preliminary Cost Annual Dollars Average PAC as Percentage
Episode Episodes TP per Episode $ % Earned/(Lost) Cost of Episode
Sepsis 135 $31,272 $30,435 $837 2.7% $112,676 $20,126 66%
CHF 88 $27,444 $27,728 $(284) (1.0%) $(24,978) $20,897 75%
COPD 80 $22,136 $21,433 $703 3.3% $55,989 $15,482 72%
Pneumonia 77 $24,665 $27,981 $(3,316) (11.9%) $(254,258) $20,640 74%
UTI 68 $26,760 $27,571 $(810) (2.9%) $(55,361) $21,953 80%
Stroke 51 $30,166 $31,442 $(1,275) (4.1%) $(65,474) $24,514 78%
Cardiac Arrhythmia 44 $18,570 $18,414 $156 0.8% $6,857 $13,222 72%
GI Bleed 40 $22,287 $21,395 $892 4.2% $35,979 $14,326 67%
MJRLE 40 $30,688 $35,087 $(4,399) (12.5%) $(174,482) $21,337 61%
PCI (IP) 38 $30,925 $29,037 $1,887 6.5% $72,347 $13,942 48%
Cellulitis 37 $23,996 $24,403 $(407) (1.7%) $(15,065) $18,871 77%
Renal Failure 36 $27,410 $27,551 $(140) (0.5%) $(5,046) $20,956 76%
AMI 30 $26,225 $24,867 $1,358 5.5% $41,199 $17,308 70%
PCI (OP) 30 $21,182 $18,707 $2,475 13.2% $73,420 $7,783 42%
Hip and Femur Except Joint 23 $45,973 $48,501 $(2,528) (5.2%) $(57,299) $35,823 74%
Spinal Fusion (noncervical) 17 $46,400 $48,107 $(1,707) (3.5%) $(29,021) $20,774 43%
Pacemaker 15 $31,516 $32,843 $(1,327) (4.0%) $(19,902) $16,309 50%
Selected by leadership for further analysis.
Green = Positive variance from TP.
Yellow = Further consideration of market dynamics and strategic priorities required.
Red = Eliminated from consideration given negative variance from TP.
Source: CMS BPCI Advanced preliminary TPs (2013 to 2016) and raw claims (2014 to 2016); received from CMS on July 9, 2018.
Notes: Figures may not be exact due to rounding. Episodes with fewer than 15 cases were excluded. PAC cost includes professional fees.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 17III. Strategic Considerations
Next Steps
» Determine the level of organizational readiness for value-based payments.
» Decide if BPCI Advanced aligns with the overarching organizational strategy.
» Evaluate the potential for physician alignment.
› Consider a gainsharing arrangement with your physicians.
» Move forward with the application process—CMS will provide the financial
performance of all 37 episodes.
» Review the financial results of the episodes.
» Identify the episodes with the greatest strategic and financial value.
» Decide on Participation or Not.
» If participating, then:
› Complete the application process.
› Implement gainsharing.
› Develop a post-acute care network.
› Manage and monitor program performance.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 18Appendix A
Episode Detail
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 19Episode Detail
Episode Definitions
Inpatient Clinical Episode DRG 1 DRG 2 DRG 3 DRG 4 DRG 5 DRG 6 DRG 7 DRG 8
Acute myocardial infarction 280 281 282
Back and neck except spinal fusion 518 519 520
Bariatric surgery1
Coronary artery bypass graft surgery 231 232 233 234 235 236
Cardiac arrhythmia 308 309 310
Cardiac defibrillator 222 223 224 225 226 227
Cardiac valve 216 217 218 219 220 221 266 267
Cellulitis 602 603
Cervical spinal fusion 471 472 473
Combined anterior posterior spinal fusion 453 454 455
Congestive heart failure 291 292 293
COPD, bronchitis/asthma 190 191 192 202 203
Disorders of liver except malignancy, cirrhosis, or alcoholic hepatitis 441 442 443
Double joint replacement of the lower extremity 461 462
Fractures, femur and hip/pelvis 533 534 535 536
GI hemorrhage 377 378 379
GI obstruction 388 389 390
Hip and femur procedures except major joint 480 481 482
Inflammatory bowel disease1
Lower extremity and humerus procedure except hip, foot, femur 492 493 494
Major bowel procedure 329 330 331
Major joint replacement of lower extremity 469 470
Major joint replacement of upper extremity 483
Pacemaker 242 243 244
Percutaneous coronary intervention 246 247 248 249 250 251 273 274
Renal failure 682 683 684
Seizures1
Sepsis 870 871 872
Simple pneumonia and respiratory infections 177 178 179 193 194 195
Spinal fusion (noncervical) 459 460
Stroke 61 62 63 64 65 66
TAVR1
Urinary tract infection 689 690
New clinical episode for MY 3.
1
A-1
CONFIDENTIAL Note: CMS has indicated that the MS-DRGs and HCPCS codes that are included will be made available at a later time.
1678.010\480360(pptx)-E2 DD 5-7-19Episode Detail
Episode Definitions (continued)
HCPCS HCPCS HCPCS HCPCS HCPCS HCPCS HCPCS HCPCS HCPCS HCPCS HCPCS HCPCS HCPCS
Outpatient Clinical Episode 1 2 3 4 5 6 7 8 9 10 11 12 13
Back or neck except spinal fusion 62287 63005 63011 63012 63017 63030 63040 63042 63045 63046 63047 63056 63075
Cardiac defibrillator 33262 33263 33264 33249 33270
TKA1
Percutaneous coronary intervention 92920 C9600 C9604 92924 92937 92928 92943 C9606 92933 C9602 C9607
1 New clinical episode for MY 3.
Note: CMS has indicated that the MS-DRGs and HCPCS codes that are included will be made available at a later time.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 A-2Appendix B
Target Price Detail
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 22Target Price Detail
TP Key Features
Efficiency Measure: Historic spending is incorporated into
the target price (TP), where higher-than-peer-group
1 spending results in a higher efficiency measure and,
therefore, higher TP.
Peer Group Trends: Clinical episode spending for participant
and peer groups is determined prospectively, to allow the
participant to achieve savings after accounting for differences 2
in case mix.
Patient Case Mix: More-complex, high-acuity patients lead to
3 a higher price adjustment, and a healthier patient population
drives a lower price adjustment.
Reward for Improvement: The pricing will reward
improvement over time, and participants must reduce spending
to achieve this savings.
4
Reward for High-Quality Care: The combination of TP
5 methodology and the composite quality score promotes
savings to Medicare while also providing high-quality care.
Source: https://www.innovation.cms.gov/initiatives/bpci-advanced.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 B-1Target Price Detail
Patient Case Mix Adjustment
Patient Case Mix Is Accounted for in Multiple Ways
1 MS-DRG and C-APC assignment
2 Patient Characteristics
Demographic characteristics (e.g.,
age, gender), long-term institutional
status, dual eligibility, HCCs,
interactions, counts, and recent
3 HCCs resource use
Individual diagnoses grouped by similar
diagnoses and illness severity; individual
HCC categories used to account for
clinical conditions in the BPCI Advanced
model
This methodology accounts for interactions between conditions. For
example, heart failure is more difficult to manage if paired with renal
impairment. The case mix will differ depending on the complexity of
patients attributed to the clinical episode in the performance year.
Source: https://www.innovation.cms.gov/initiatives/bpci-advanced.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 B-2Target Price Detail
Standardized Baseline Spending
Spending in the Baseline Period Suburban
Urban Academic
» CMS adjustments are removed when Hospital
Medical Center
calculating historical clinical episode
costs and making comparisons to other Rent Teaching Rent Teaching Costs
ACHs. This allows for comparison of
Proportion of Disproportionate
the intensity of services provided, Labor Uninsured Labor
Share
independent of context.
» These adjustments are reapplied in the CMS adjusts payments for:
final step of setting ACH benchmarks. » Regional labor costs and practice expenses (i.e., hospital wage indexes and
geographic practice cost indexes).
» Graduate medical education and indirect medical education.
» Serving a large population of poor and uninsured patients (i.e.,
disproportionate share payments).
Historical Efficiency
The efficiency calculation quantifies the Hospital A Hospital B
relationship between resources utilized Excellent Outcomes Excellent Outcomes
to achieve an outcome and outcomes
Low High
achieved. In this example, hospital A is Testing Unit Testing Unit
more efficient because it uses less Volumes Volumes
Inpatient Days Inpatient Days
services but achieves the same clinical
outcome as hospital B. Post-Acute Care Days Post-Acute Care Days
Readmissions Readmissions
Source: https://www.innovation.cms.gov/initiatives/bpci-advanced.
Cost alone does not reflect efficiency.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 B-3Target Price Detail
Peer-Adjusted Trend Factor
Hospitals are not compared to specific peer hospitals. Instead, these factors are
accounted for in a multivariate model.
Bundled Clinical Episodes Compare Peers on the Basis of the Type and
Quantity of Services Provided
Factors considered in identifying ACH peers include:
Bed Count Safety Net Status
Rural/Urban Setting Census Division
Academic Medical Center Status
If all your peers achieve more-efficient care, over time you’ll be held to that same standard.
» Example: More-efficient use of post-acute care in orthopedic bundles
Conversely, if all your peers start using a new treatment that changes costs and outcomes, it will adjust
your TP.
» Example: New, expensive curative treatment
Source: https://www.innovation.cms.gov/initiatives/bpci-advanced.
CONFIDENTIAL
1678.010\480360(pptx)-E2 DD 5-7-19 B-4Target Price Detail
Implications
The final TP will not be determined until the end of October 2019. While most
changes will be linked to the Medicare fee schedule through the SBS, adjustments
to the PCMA could have a greater impact on the final TP.
Methodology Implication
» Historic spending is adjusted by an efficiency
» Actual spending will be updated quarterly to
measure that is a ratio of observed to predicted
reflect changes to the Medicare fee schedule.
spending.
SBS » Observed spending that is higher than
» Adjustments to this component are expected to
be minor.
predicted spending will increase the SBS.
» PCMA is the ratio between average case mix–
» PCMA will be adjusted at the end of the MY to
adjusted spending and average predicted
reflect performance year case mix
baseline spending across all hospitals.
PCMA » If case mix changes relative to the average, TP
» A higher PCMA indicates a higher-acuity case
will also be affected.
mix and a higher TP.
» This factor adjusts for persistent differences in
the peer group trends through the end of MY 1.
Peer This factor will not exhibit large fluctuations, either
» Factors considered in identifying peers include in increases or decreases in spending, that cannot
Adjustment bed count, rural/urban setting, academic/ be expected to persist.
Trend Factor nonacademic status, safety net status, and
census division.
CONFIDENTIAL
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