After finalizing the cancellation of its episode payment and cardiac rehabilitation incentive payment models, many were left wondering whether the Trump administration opposed all bundled payment models, or only those in which participation was mandatory. Today, these questions began to be answered as the Centers for Medicare & Medicaid Services (CMS) announced a new bundled payment program: Bundled Payments for Care Improvement Advanced (BPCI Advanced). The model, developed and administered by the Center for Medicare & Medicaid Innovation (CMMI), will begin with its initial cohort of voluntary participants on October 1, 2018 and run through December 31, 2023.

BPCI Advanced will provide a single, retrospective bundled payment to healthcare providers for 32 defined clinical episodes (29 inpatient, 3 outpatient). Each episode will last 90 days, and payment will be based on performance on 7 quality measures. CMS may revise the list of clinical episodes during the performance period on an annual basis, and each participant must agree to be held accountable for at least one of them. All patient expenditures during the 90 day period (excluding outlier payments), will be semi-annually compared to a target price, after which CMS will either make a bonus payment to participants or require repayment.

Two Types of Participants

CMS defines both “convener” and “non-convener” participants. Conveners bring together downstream participants who generally initiate episodes of care, coordinates patient care between participants, and bears the financial risk for the care provided. Non-coveners are those which do not bear risk on the behalf of others. All participants are required to enter into a participation agreement with CMS, and in addition to the possibility of bonus payments for meeting price and quality targets, all participants will also take on downside risk for overexpenditures and poor quality performance. In addition, participation in BPCI Advanced will qualify as participation in an Advanced Alternative Payment Model (Advanced APM) for purposes of the CMS Quality Payment Program.

Quality Measures

CMS has initially selected seven quality measures for the BPCI Advanced model. The first two apply to all clinical episodes:

• All-cause Hospital Readmission Measure (NQF #1789)
• Advanced Care Plan (NQF #0326)

In addition, these measures will apply to relevant clinical episodes:

• 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)

Application and Timeline

The application period for the BPCI Advanced model will open January 11, 2018 and close on March 12, 2018. Initial target prices will be released in May 2018, and participant agreements will be offered in June, with signed agreements due back in August. At that time, participants will select the clinical episodes in which they will participate, before the performance period begins on October 1, 2018.

More information, including a request for applications and all application materials, can be found on CMS’ BPCI Advanced site. Applied Policy has extensive experience working with CMMI and in the implementation of bundled payment models, and we are available to help your organization decide if BPCI Advanced might be right for your patients. Contact us at gpugh@appliedpolicy.com, or 202-558-5272.