March 5, 2018
Bundled Payments for Care Improvement Advanced (BPCI Advanced), a new initiative from the Center for Medicare and Medicaid Innovation, was among topics of discussion at the American Society of Anesthesiologists’ practice management conference in New Orleans. We provide an overview of this program and links to resources. As in the past with other new programs, anesthesia practices may want to take this opportunity to learn, observe and see how the model unfolds.
The Center for Medicare and Medicaid Innovation’s (CMMI’s) most recent initiative, Bundled Payments for Care Improvement Advanced (BPCI Advanced), announced earlier this year, will test a new iteration of bundled payments for 29 inpatient episodes and three outpatient episodes, marking the federal government’s first foray into bundles for outpatient care. (See here and here for background and history on bundled payments.)
The model, which was among topics of discussion in general sessions at the American Society of Anesthesiologists’ (ASA) PRACTICE MANAGEMENT™ 2018 in New Orleans, gives anesthesiologists and nurse anesthetists an opportunity to contribute to innovation and the continuous reengineering of care in the transition to value catalyzed by the Quality Payment Program (QPP). It’s an option for QPP participation that anesthesia practices might want to consider pursuing, either now or farther down the road.
“While experience in a perioperative surgical home or as part of ASA’s PSH Learning Collaborative is not a requirement for BPCI Advanced participation, it could prove quite helpful,” Sharon Merrick, director of payment and practice management for the ASA, said in a comment via email.
Unlike its forerunner, BPCI, the new program will qualify as an advanced alternative payment model (APM) in the QPP for the 2019 performance year. Participants may become Qualified APM Participants (QPs) and be eligible for a five percent APM incentive payment on their Medicare Part B billing between 2019 and 2024.
While the QPP’s Merit-Based Improvement Payment System (MIPS) is structured around quality reporting by individual clinicians or group practices, BPCI Advanced, like BPCI, revolves around more broadly coordinated efforts to improve care and reduce expenditures for episodes across multiple settings and types of services, including inpatient and outpatient hospitals, physician services, skilled nursing facilities, clinical laboratories and hospices, among others. Unlike BPCI, however, BPCI Advanced designates two types of entities as “episode initiators”—physician group practices and acute care hospitals. (These entities would bear financial risk only for their own performance. A table comparison of bundled payment programs is available here.)
Because the program is an APM, payment will be tied to performance on a number of quality measures. CMS will provide preliminary target prices (benchmark prices) in advance of the performance period for each model year, and these prices will be risk-adjusted based on participants’ actual patient case mix.
The program will use a retrospective payment approach in which participants will either receive payment from or owe payment to CMS after the agency reconciles all expenditures for the clinical episode against the target price.
After a period of uncertainty following the cancellation of the planned cardiac rehabilitation bundle and cuts to the scope of an orthopedic surgery bundle in 20171 (both mandatory programs), CMMI’s announcement of this voluntary program indicates the current administration’s interest in keeping bundles on the table as a method of driving value. As this eAlert was being written, the deadline to submit an application for BPCI Advanced was March 12, 2018. (The request for applications containing detailed information on the program is available here; application submission does not obligate submitters to participate in the initiative.)
However, in a February 12 letter to CMS Administrator Seema Varma, the American Hospital Association urged the agency to extend the deadline for applications to April 16, 2018, expressing concern regarding a “lack of sufficient operational detail about the model, making it difficult for hospitals and clinicians to make well-informed decisions as to participation.” AHA stated its appreciation for CMS’s use of a risk-adjustment methodology to determine payment through BPCI Advanced that “prevents penalizing hospitals treating the sickest, most complicated and most vulnerable patients,” but asked the agency to consider adding policies for determining target prices to “help ensure that a hospital does not have to compete against its own best performance.”
A recent article on Health Affairs’ blog also praised the model’s use of a risk-adjustment methodology but noted that the program’s voluntary rather than mandatory participation could hamper efforts to assess the impact on cost and quality in a generalizable way that “may preclude a definitive answer on whether bundled payments are suited for expansion to the entire Medicare population.”
The first cohort of participants will begin participation in BPCI Advanced on October 1, 2018, with a performance period that runs through December 31, 2023. However, a second application opportunity will also be provided in 2020.
We encourage you to carefully review the program materials and request for application in order to make an informed decision on whether BPCI Advanced would or would not be a viable option for your group. As in the past with other new programs, anesthesia practices may want to take this opportunity to learn, observe and see how the model unfolds.
A PowerPoint presentation and mp4 webcast recording on BPCI Advanced, including an explanation of the program’s retrospective payment methodology, are available here and here.
With best wishes,
Tony Mira
President and CEO
Reference:
1 Federal Register, Vol. 82, No. 230, Friday, December 1, 2017, Rules and Regulations, p. 57066.
