Yes, the rumors are true. CMS has announced the launch of a new voluntary payment model called Bundled Payments for Care Improvement Advanced (or BPCI-A). If you’re too busy actually treating patients to keep up with the wacky world of CMS, you needn’t worry, our team at TTG Advisors has sifted through policy briefs, websites, and webinars to bring you the most up-to-date information. Let’s dig in.
The Executive’s Summary
For qualifying episodes of care, payments for the physician/physician group, acute care hospital, and other providers will be combined into a single amount and distributed. If, in retrospect, the quality of care across these entities was determined to exceed a pre-determined benchmark, CMS will provide a 5% incentive payment in addition to reimbursement of up to 20% of total cost savings. Sound good, right? Well, if you perform significantly worse than your benchmark, you can be financially liable for up to 20% of costs above the target price of each episode. Also, performing poorly on quality measures can lead to a downward adjustment of cost savings by as much as 10%. Ouch.
After receiving pricing targets/benchmarks from CMS, BCPI-A participants will select one or more of the 32 eligible clinical episodes for the program. Clinical episodes are “triggered” by the MS-DRG (acute care hospitals) or HCPC codes (provider/provider groups) located here. Patient encounters within the 90 days following the initiation of the episode will be included in CMS’ assessment of quality and cost. Every six months CMS will reconcile the total cost per episode with the expected cost. Cost savings will lead to a payment of up to 20% of savings, with an additional 5% Advanced APM incentive. Performing significantly worse than target can result in paying back money to CMS (up to 20% of costs above the pricing target). Exceeding quality targets can result in +/- 10% adjustment to either cost savings from CMS or repayment to CMS.
Participants in BCPI-A include both Convener Participants and Non-Convener Participants. Conveners are organizations that bring together downstream healthcare entities (i.e., Episode Initiators) and importantly, bear the financial risk on behalf of all participants in the continuum. These organizations may also limit the administrative costs associated with program participation (e.g., hiring additional staff) by providing their own ancillary services. These organizations are expensive, but the peace of mind of an all-inclusive service is often priceless. Non-Convener participants include physicians/physician groups and acute care hospitals.
What are the Risks?
Non-Convener participants operating outside of a Convener, will bear process costs associated with participation. These could include: upgraded technology, data analytics, and possible care coordination staff. Non-Convener participants aren’t given a “ramp up” time and are expected to meet pricing and quality targets in Year 1 of the program. Further, because this program is retrospective in nature, CMS will pay the full amount for services rendered but may, after biannual reconciliation, require up to 20% of excess costs to be reimbursed. Finally, once you’ve selected your episodes, you won’t be able to change them until 2020-so choose wisely and with your pocketbook in mind.
What are the potential upsides?
For the Patient
It’s easy to fall through the cracks of our fragmented healthcare system. The BCPI-A program requires providers and ACHs to view the needs of the patient globally and take ownership over their ability to safely navigate the continuum of care. The bottom line is that CMS is betting big on this equation panning out:
Care coordination and High-quality referrals = Better Patient Outcomes
For your Wallet
Successfully producing cost savings and delivering quality care can result in a significant financial upside—to the tune of 20% of total cost savings. Plus, after surpassing CMS benchmarks, your organization is likely to receive a 5% APM incentive payment. So, if you already have solid referral partners and a care coordination strategy in place, you’ll essentially be incentivized to provide the same caliber of care you’re known for. Last but certainly not least, your participation in an Advanced APM means that you’ll be exempt from MIPS reporting. This bears repeating: Your participation in an Advanced APM means that you’ll be exempt from MIPS reporting. Mazel Tov.
Monday, March 12th is the deadline to submit a BCPI-A interest form/Application to CMS. This application is non-binding but a requirement for CMS to provide your organization with its historical data and benchmarks they’ll hold you accountable for. The TTG team can assess which episodes can provide the greatest amount of upside and least amount of risk to your organization. Your chosen episodes must be submitted by August of 2018 and the performance period will last the entirety of the 2019 calendar year.
TTG Advisors is a healthcare consulting company servicing practices, health centers, ASCs, and hospitals throughout the United States. Our suite of services ranges from day-to-day practice management to the implementation of new payment models, like BCPI-A. Regardless of your needs our talented team at TTG Advisors is equipped to facilitate your success.
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