BPCI – Advanced

Lisa Benton, Consultant

October 29, 2019

Today’s Presenter

Lisa BentonConsultant

Agenda

• Model Overview

• Objectives

• Who Can Participate

• Advanced Alternative Payment Model Criteria

• Defining the Clinical Episodes

• Monitoring and Evaluation

• Timeline

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Model Overview

• Voluntary bundled payment model

• Single payment and risk track with a 90-day episode period

• 31 Inpatient Clinical Episodes

• 4 Outpatient Clinical Episodes

• Qualifies as Advanced Alternative Payment Model (Advanced APM)

• Payment tied to performance on quality measures

• Preliminary Target Prices provided prospectively

• Final Target Prices reflect realized patient case mix4

Objectives

• Financial Accountability

• Care Redesign

• Data Analysis and Feedback

• Health Care Provider Engagement

• Patient and Caregiver Engagement

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BPCI-Advanced Participants

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Convener Participant• Brings together Downstream

Episodes Initiators (Els)• Facilitates coordination • Bears and apportions financial risk

An El is a Medicare provider that can trigger Clinical Episodes by the

submission of a claim for either an inpatient hospital stay (Anchor Stay) or an outpatient procedure (Anchor Procedure)

Non-Convener Participant• Is the El• Bears financial • Does not bear risk

Advanced Alternative Payment Model Criteria

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Financial Risk

CEHRT

Quality

• Advanced APM: bear risk for monetary losses of more than a nominal amount

• BPCI Advanced: financially at risk for up to 20% of the final Target Price for each Clinical Episode

• Advanced APM: use CEHRT

• BPCI Advanced: attest to using CEHRT prior to participation

• Advanced APM: linked to quality measures comparable to Merit-Based Incentive Payment System measures

• BPCI Advanced: CMS calculates a quality score for each quality measure at the Clinical Episode level

Defining the Clinical Episodes

• Anchor Stay – inpatient stay at an ACH with a qualifying Medicare Severity-Diagnosis Related Group (MS-DRG) billed to Medicare FFS by an El– Clinical Episode length: Anchor Stay + 90 days, with 90 days

starting on the day of discharge

• Anchor Procedure – outpatient procedure (identified by a Healthcare Common Procedure Coding System (HCPCS) code) on an associated Hospital Outpatient facility claim billed to Medicare FFS by an El– Clinical Episode length: Anchor Procedure + 90 days beginning on

the day of completion of the outpatient procedure

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Monitoring and Evaluation

CMS may monitor Model Performance by:

• Tracking claims data and medical reviews

• Ad hoc reviews and analysis of financial and quality performance measurements

• Site visits, surveys and interviews with Participants, EIs, Participating Practitioners, Beneficiaries, and other parties

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BPCI-Advanced Timeline

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October 2018 2018 2019 2020 2023

BPCI Advanced

Model Performanc

e Period began

BPCI Advanced

Model Year 1

BPCI Advanced

Model Year 2

BPCI Advanced

Model Year 3

BPCI Advanced

Last Model Year

Helpful Resources

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• https://www.qualidigm.org/payment-models/

Qualidigm Payment Model Homepage

• https://innovation.cms.gov/initiatives/bpci-advanced

BPCI-Advanced – Bundled Payments for Care Improvement Advanced Model

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Questions?Please submit questions via the chat box

Contact Us

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Lisa Benton

lbenton@qualidigm.org

860.632.6309

Follow Us On Social Media

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@Qualidigm @Qualidigm@Qualidigm

@Qualidigm @Qualidigm_org