BPCI Advanced Model Extended with Price Changes | Foley Hoag LLP
Key points to remember:
- The Bulk Payments for Improved Care (BPCI Advanced) model has been extended for two years, until December 31, 2025, with the possibility for new entities to join the model from 2024.
- The model is a Medicare fee-for-service model run by the Center for Medicare and Medicaid Innovation (CMMI) that involves participants taking responsibility for the cost and quality of care during certain defined clinical episodes, which could be triggered by either an inpatient stay or outpatient procedure.
- Current participants in the model include both organizing and non-organizing participants; however, entities applying to begin participating in the model from 2024 must be Medicare-enrolled acute care hospitals (ACHs) and group medical practices (PGPs) or Medicare Accountable Care Organizations (ACOs).
- Along with the model extension, CMMI announced some changes to the model’s financial methodology that will take effect in 2023.
On October 13, 2022, CMS announced that it would extend the Bulk Payments for Improved Care (BPCI Advanced) model for two years, with the ability for new entities to join the model from 2024. CMS has also announced some changes in the financial model of the model. methodology which will enter into force next year.
BPCI Advanced is an Advanced Alternative Payment Model (Advanced APM) under the Quality Payment Program (QPP). It was created by the Center for Medicare and Medicaid Innovation (CMMI) to test whether linking payments for a clinical episode to cost and quality of care can influence healthcare providers to reduce Medicare spending. while maintaining or improving the quality of care. Clinical episodes are defined as an inpatient stay or outpatient procedure and include all non-excluded clinical laboratory services, durable medical equipment, medical services, Part B drugs, nursing home services qualified, inpatient rehabilitation facility services, long-term care hospital services, home health agency services and palliative care services.
According to the financial methodology of the model:
- A clinical episode is triggered by a hospitalization (anchor stay) or an outpatient procedure (anchor procedure)
- Care during the episode is paid for as part of Medicare’s fee-for-service
- The clinical episode is assigned to a model participant
- After each performance period, the quality and cost performance of each assigned clinical episode is evaluated to determine whether the participant has earned a net payment reconciliation amount or owes CMS a reimbursement amount.
Model participants include both organizing participants and non-organizing participants. An organizing participant does not need to be a Medicare-enrolled vendor or provider and instead brings together downstream episode initiators – namely group medical practices (PGPs) and/or acute care hospitals (ACH) – to participate in the model. A non-organizing participant must itself be a PGP or an ACH.
As of December 31, 2021, more than 1.2 million Medicare beneficiaries have received care from BPCI Advanced Model participants, and more than 1,800 ACHs in coordination with 69,867 physicians have engaged in plan redesign activities. care as part of the model.
Extension and model changes
The BPCI Advanced Model launched on October 1, 2018 and was originally scheduled to end on December 31, 2023, but will now end on December 31, 2025. As part of the model extension, CMS will also issue a Request for Applications (RFA) to solicit a third cohort of model participants to begin participating in the model on January 1, 2024. Applicants are limited to Medicare-enrolled ACHs and PGPs, and Medicare Accountable Care Organizations (ACOs), although participants existing organizers can participate in the two-year extension of the model (2024-2025). Organizer Participants and Non-Organizer Participants active during Model Year 6 (2023) will have the option of continuing to participate in the model during the extension period by signing an amended and updated Model Year 7 Participant Agreement ( 2024).
CMS is also making the following changes to the model financial methodology for model year 6 (2023):
- Reduced the CMS rebate for medical clinical episodes (as opposed to surgical clinical episodes) from 3% to 2%, making it easier for participants to earn an NPRA on those episodes
- Reduce the peer group trend factor adjustment cap for all clinical episodes from 10% to 5%, limiting the impact of peer group trends on the target price calculation
- Changed the upper extremity major joint replacement clinical episode to include outpatient total shoulder arthroplasty procedures, so that the clinical episode can be triggered either by an inpatient anchor stay or by an outpatient anchoring procedure
- Hold participants accountable for all clinical episodes in which the beneficiary has a diagnosis of COVID-19 during the clinical episode. This was based on concerns that the historical exclusion of clinical episodes when the beneficiary had a diagnosis of COVID-19 led to a reduction in the volume of episodes
Coroner Tyrus Jackson also contributed to this alert.