CMS Announces New Medicare Episode Payment Bundle- Here’s what you need to know

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    Whitfield L. Knapple, MD, FACG
    Chair, Legislative and Public Policy Council

    This week, the Centers for Medicare & Medicaid Services (CMS) announced a new voluntary episode payment model, the “Bundled Payments for Care Improvement Advanced” (BPCI Advanced).  This will test a new iteration of bundled payments for 32 Clinical Episodes (see below for GI episodes).  BPCI Advanced will qualify as an Advanced Alternative Payment Model (APM) under MACRA, or the Quality Payment Program.  This means that ACG members in group practices can select to be held accountable for certain inpatient episodes of care instead of participating in MIPS (there are no outpatient-related GI episodes of care at this time).

    Background

    ACG members meeting certain reporting thresholds must either participate in MIPS, or in a CMS-approved Advanced APM.

    A bundled payment model 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 patient during an episode of care.  The goal being to motivate health care providers to furnish services efficiently, to better coordinate care, and to improve the quality of care (and save the system money). Health care providers receiving a bundled payment may either realize a gain or loss, based on how they manage resources and total costs throughout each episode of care. According to CMS, 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.

    BCPI Advanced Model Overview

    The newly announced BPCI Advanced model is defined by following characteristics:

    1. Participation is voluntary
    1. Based on a single retrospective bundled payment and one risk track, with a 90-day Clinical Episode duration
    2. Qualifies as an Advanced APM under MACRA (or the Quality Payment Program)
    3. Payment is tied to performance on quality measures
    4. Preliminary “Target Prices” are provided in advance of each Model Year

    BPCI Advanced will operate under a “total-cost-of-care” concept, where the total Medicare fee-for-services (FFS) spending on all items and services furnished during the clinical episode will be included as expenditures for purposes of the “Target Price” and reconciliation calculations (exclusions do apply).

    Participants

    Participating hospitals and physician group practices (PGPs) must commit to be held accountable for one or more clinical episodes beginning in October 2018, and may not add or drop such Clinical Episodes until January 1, 2020.

    For purposes of BPCI Advanced, a “Participant” is defined as an entity that enters into a Participation Agreement with CMS to participate in the Model. BPCI Advanced will require a downside financial risk of all Participants from the outset of the Model Performance Period.

    GI Clinical Episodes

    The BPCI Advanced models will initially include 29 inpatient clinical episodes and 3 outpatient clinical episodes.  CMS may elect to revise the Clinical Episodes in BPCI Advanced on an annual basis beginning January 1, 2020.  Among the list of 29 Inpatient Clinical Episodes, there are 5 related to GI:

    • Disorders of the liver, excluding malignancy, cirrhosis, alcoholic hepatitis *
      *(New episode added to BPCI Advanced)
    • Gastrointestinal hemorrhage
    • Gastrointestinal obstruction
    • Major bowel procedure
    • Sepsis

    At this time, there are no GI episodes among the list of the 3 Outpatient Clinical Episodes.

    Attribution

    CMS assigns or “attributes” patients and services based on the following hierarchy: (1) the PGP that submits a claim that includes the National Provider Identifier (NPI) for the attending physician, and a corresponding Part B claim billed under the participating PGP’s Tax Identification Number (TIN); (2) the PGP that submits a claim that includes NPI for the operating physician and a corresponding Part B claim during the Anchor Stay or Procedure billed under the PGP’s TIN; and (3) the hospital where the services that triggered the clinical episode were furnished.

    Time Period

    A BPCI Advanced clinical episode is structured to begin either at the start of an inpatient admission to a hospital (the “Anchor Stay”) or at the start of an outpatient procedure (the “Anchor Procedure”). Inpatient admissions that qualify as an Anchor Stay will be identified by MS-DRGs, while outpatient procedures that qualify as an Anchor Procedure will be identified by HCPCS codes.

    The clinical episode will end 90 days after the end of the Anchor Stay or the Anchor Procedure.

    CMS will also monitor the 30 days following the end of the clinical episode to monitor for any potential cost-shifting or post-episode spending

    Quality Measures

    CMS has selected 7 quality measures for the BPCI Advanced Model. Two of them, “All-cause Hospital Readmission Measure” and “Advanced Care Plan,” will be required for all Clinical Episodes.

    The other five quality measures will only apply to certain clinical episodes.

    Model- Timeline

    Participation begins on October 1, 2018.  The BPCI Advanced model period performance will run through December 31, 2023. CMS will provide a second application opportunity in January 2020.

    CMS developed a model timeline: Roadmap – Model Timeline (PDF).

    How to Apply

    The Request for Applications (RFA) for BPCI Advanced was released on January 9, 2018 and closes on March 12, 2018. The RFA is now available (PDF).

    ACG’s Next Steps

    Please stay tuned for more guidance as ACG reviews the details for these GI episode payment bundles.

    Whitfield L. Knapple, MD, FACG

    Chair, ACG Legislative and Public Policy Council

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