Becker’s – CMS launches new bundled payment model: 6 things to know

CMS announced a new voluntary bundled payment model on Tuesday, which is the first advanced alternative payment model introduced by the Trump administration.

Here are six things to know about the bundled payment model.

1. The new model, called Bundled Payments for Care Improvement Advanced, includes 32 clinical episodes, with 29 in the inpatient setting and three in the outpatient setting. The clinical episodes may change in the future, as CMS may elect to revise them on an annual basis beginning Jan. 1, 2020.
2. Under the program, provider payments will be based on quality performance during a 90-day episode of care. A clinical episode will begin at the start of an inpatient admission to an acute care hospital, which CMS referred to as the “anchor stay,” or at the beginning of an outpatient procedure, the “anchor procedure.” The clinical episode will end 90 days after the end of the anchor stay or the anchor procedure.
3. CMS selected seven quality measures for BPCI Advanced. Two of them, the all-cause hospital readmission measure and the advanced care plan measure, will be required for all clinical episodes. The other five measures will only apply to select clinical episodes.
4. BPCI Advanced will qualify as an advanced APM under the Quality Payment Program, meaning participants will be eligible for bonuses under the Medicare Access and CHIP Reauthorization Act.
5. The first cohort of providers will start participation in the model Oct. 1, and the performance period will run through Dec. 31, 2023. Providers selected to participate in BPCI Advanced beginning Oct. 1 must be held accountable for at least one clinical episode and may not add or drop clinical episodes until Jan. 1, 2020.
6. Providers have until March 12 to apply. CMS will provide a second application opportunity for BPCI Advanced in January 2020.

Additional Info from the CMS Website:

BPCI Advanced
The Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (Innovation Center) is announcing a new voluntary episode payment model, Bundled Payments for Care Improvement Advanced (BPCI Advanced or the Model) that will test a new iteration of bundled payments for 32 Clinical Episodes and aim to align incentives among participating health care providers for reducing expenditures and improving quality of care for Medicare beneficiaries. BPCI Advanced will qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.

The first cohort of Participants will start participation in the Model on October 1, 2018, and the Model Period Performance will run through December 31, 2023. CMS will provide a second application opportunity in January 2020.

One of the most important goals at CMS is fostering an affordable, accessible healthcare system that puts patients first. A bundled payment methodology involves combining the payments for physician, hospital, and other health care provider services into a single bundled payment amount. This amount is calculated based on the expected costs of all items and services furnished to a beneficiary during an episode of care. Payment models that provide a single bundled payment to health care providers can motivate health care providers to furnish services efficiently, to better coordinate care, and to improve the quality of care. Health care providers receiving a bundled payment may either realize a gain or loss, based on how successfully they manage resources and total costs throughout each episode of care. A bundled payment also creates an incentive for providers and suppliers to coordinate and deliver care more efficiently because a single bundled payment will often cover services furnished by various health care providers in multiple care delivery settings.

Model Overview
BPCI-Advanced is defined by following characteristics:
• Voluntary Model
• A single retrospective bundled payment and one risk track, with a 90-day Clinical Episode duration
• 29 Inpatient Clinical Episodes
• 3 Outpatient Clinical Episodes
• Qualifies as an Advanced APM
• Payment is tied to performance on quality measures
• Preliminary Target Prices provided in advance of the first Performance Period of each Model Year

Can participate as a Non-Convener Participant:
• Acute Care Hospitals (ACHs)
• Physician Group Practices (PGPs)

Can participate as a Convener Participant:
• Eligible entities that are Medicare-enrolled providers or suppliers
• Eligible entities that are not enrolled in Medicare
• Acute Care Hospitals (ACHs)
• Physician Group Practices (PGPs)

A Convener Participant is a type of Participant that brings together multiple downstream entities, referred to as “Episode Initiators (EIs).” A Convener Participant facilitates coordination among its EIs and bears and apportions financial risk under the Model.

A Non-Convener Participant is a Participant that is in itself an EI and does not bear risk on behalf of multiple downstream Episode Initiators.

For a list of the 29 Inpatient Clinical Episodes, please see below:
• Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis *
*(New episode added to BPCI Advanced)
• Acute myocardial infarction
• Back & neck except spinal fusion
• Cardiac arrhythmia
• Cardiac defibrillator
• Cardiac valve
• Cellulitis
• Cervical spinal fusion
• COPD, bronchitis, asthma
• Combined anterior posterior spinal fusion
• Congestive heart failure
• Coronary artery bypass graft
• Double joint replacement of the lower extremity
• Fractures of the femur and hip or pelvis
• Gastrointestinal hemorrhage
• Gastrointestinal obstruction
• Hip & femur procedures except major joint
• Lower extremity/humerus procedure except hip, foot, femur
• Major bowel procedure
• Major joint replacement of the lower extremity
• Major joint replacement of the upper extremity
• Pacemaker
• Percutaneous coronary intervention
• Renal failure
• Sepsis
• Simple pneumonia and respiratory infections
• Spinal fusion (non-cervical)
• Stroke
• Urinary tract infection

For a list of the 3 Outpatient Clinical Episodes, please see below:
• Percutaneous Coronary Intervention (PCI)
• Cardiac Defibrillator
• Back & Neck except Spinal Fusion

Quality Measures
CMS has selected seven quality measures for the BPCI Advanced Model. Two of them, All-cause Hospital Readmission Measure and Advance Care Plan, will be required for all Clinical Episodes. The other five quality measures will only apply to select Clinical Episodes.

• All-cause Hospital Readmission Measure (NQF #1789)
• Advanced Care Plan (NQF #0326)
• Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF #0268)
• Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF #1550)
• Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF #2558)
• Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (NQF #2881)
• AHRQ Patient Safety Indicators (PSI 90)


Original article can be accessed here.

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