The Bundled Payments for Care Improvement Advanced Model (BPCI-Advanced) is a voluntary advanced alternative payment model that began in October of 2018, and is set to continue through 2023. The model serves Medicare fee-for-service (FFS) beneficiaries and allows participants to take on risk for the 90-day duration of up to 31 eligible inpatient clinical episodes and 4 eligible outpatient clinical episodes. Total Medicare FFS expenditures for the 90-day clinical episodes are reconciled against Target Prices, enabling participants to receive a single retrospective payment for their attributed clinical episodes, with payment reconciliation done on a semi-annual basis.

In September of 2020, the Centers of Medicare and Medicaid Services (CMS) released updates to Model Year 4 of BPCI-Advanced, which went into effect in January of 2021. The model changes were designed to help ensure the program achieves its goal of providing Medicare savings without sacrificing patient care quality. The changes will mitigate participant clinical episode selection bias, improve Target Price accuracy, and help CMS ensure reconciliation payments are made as a result of true cost reductions versus participant regression to the mean.

Below is a breakdown of the five major changes made by CMS to Model Year 4, and the impact these changes will have on BPCI-Advanced participants.

Change #1: Clinical Episode Service Line Groups (CESLGs)

The first major change to Model Year 4 is the creation of clinical episode service line groups. With this new change, the 35 BPCI-Advanced clinical episodes are bucketed into 8 clinical episode service line groups; cardiac care, cardiac procedures, gastrointestinal surgery, gastrointestinal care, neurological care, medical and critical care, spinal procedures, and orthopedics.

With this change, participants are now required to select clinical episode service line groups and must participate in all the clinical episodes within each grouping unless they do not meet the minimum volume threshold for any component clinical episode during the baseline period. Additionally,  participation in clinical episode service line groups will be locked in for three years, meaning participants cannot drop these groupings and still remain in the program.

Change #2: New Clinical Episode Overlap Methodology

The second major model change is the introduction of a new clinical episode overlap exclusion methodology. In Model Year 4, CMS is excluding any clinical episodes that would have been normally triggered while a beneficiary has an ongoing separate clinical episode. This in effect means that no BPCI-Advanced clinical episodes will be overlapping. It is important to note that overlapping clinical episodes will be excluded regardless of whether the initial ongoing episode was attributed to a BPCI-Advanced participant or not.

Change #3: Realized Peer Group Trend Adjustment

The third major change to Model Year 4 is the introduction of a retrospective peer ground trend adjustment. With the new update, CMS will adjust final Target Prices at Reconciliation for peer group trends found in Performance Period Clinical Episodes spending. This means that CMS will cap the difference between the realized retrospective peer-group trend factor from the preliminary prospective peer-group trend factor at 10% of the preliminary prospective trend. Peer groups are based on relevant hospital characteristics, such as region, size, academic medical center status, safety net status, and urban versus rural status.

Change #4: Removal of Physician Group Practice (PGP) Offset

The fourth major model change in Model Year 4 is that CMS will remove the PGP offset used in PGP target price construction. This means that each clinical episode category will have a single target price that does not vary irrespective of the individual PGP that triggered the episode.

This change will create the same Target Prices for PGPs as acute care hospitals (ACHs), except for their respective patient Case Mix Adjustments (CMA), simplifying the program’s pricing methodology and easily allowing for program scale. In terms of participant impact, this change could lead to possible increases in savings for historically efficient PGPs and a possible reduction in savings for historically inefficient PGPs.

Change #5:  Major Joint Replacement of the Lower Extremities Risk Adjustment

The final major program change is that CMS will add procedure flags to the Model Year 4 risk adjustment model for the Major Joint Replacement of Lower Extremities (MJRLE) clinical episode. This includes flags for; partial knee arthroplasty, total knee arthroplasty, partial hip arthroplasty, total hip arthroplasty and hip resurfacing, ankle and reattachments, and others. CMS will use these flags to improve the precision of the MJRLE clinical episode category risk adjustment and Target Prices.

In light of these recent changes, BPCI-Advanced participants should keep in mind two key considerations; the requirement of rapid financial assessments and decision making, and the likelihood that CMS will introduce mandatory bundled payment programs after the initial program conclusion in 2023. To help ensure they meet their programs’ clinical and financial goals, participating organizations should incorporate proper workflows and supporting infrastructures, and prepare for the future mandatory bundled payments value-based care programs that are to come.

COVID-19’s impact on physician organizations has amplified the risks of variability with fee-for-service (FFS) payment models, and highlighted the importance of shifting towards value-based care and alternative reimbursement models. Primary care physicians will have increased opportunities to embrace value-based care models in 2021, with CMS’s Primary Care First Model Options scheduled to begin in January for the Primary Care First (PCF) component, and April for the Seriously Ill Population (SIP). The voluntary payment builds on the existing Comprehensive Primary Care Plus payment model, with the goals of reducing Medicare spend and improving quality and patient access to care for patients with complex conditions.

Model Payment Structure

In an effort to reduce organizational administrative and billing burdens, CMS has intentionally focused on making the Primary Care First Model’s payment mechanisms simple and straightforward for participants. A monthly population-based payment and flat primary care visit fees make up a “Total Primary Care Payment” for participants, which is then adjusted by up to 50% based on performance measures.  Below are the details for each component of the model’s payment structure:

Monthly Population Payment:

• Monthly population payment that supports practice enhancements and services to effectively care manage patient populations
• Monthly payment per beneficiary ranges from $28 PBPM to $175 PBPM, with the amount standardized for all patients within a practice and dictated by the risk level of a participant’s population
• Monthly payment amount is reduced with a leakage adjustment, accounting for if patients receive primary care outside of participant’s practice

Flat Primary Care Visit Fee:

• Payment for in-person treatment, simplifying billing process and payment projections
• Flat visit fee of $40.82 per face-to-face encounter

Performance-Based Adjustment:

• Quarterly performance adjustment to the Total Primary Care Payment of up to 50% upside or 10% downside
• Specific performance measures depend on participant’s risk level
• Acute Hospital Utilization will be a key measure for lower-risk participants in year 1 and Total Per Capita Cost will be a key measure for higher risk participants in year 1

Preparing for Success

Primary Care First Model Options offers participants the opportunity to meaningfully increase practice revenue, remove the variability of FFS reimbursement, and strengthen relationships between patients and providers. As participants plan their strategies for success, it is important to consider capabilities that maximize the performance-based adjustment measurements as they support optimal patient outcomes and can drive up to 50% more revenue for practices. Real-time admission, discharge, and transfer (ADT) data that provides actionable insights into patient care events will be a critical resource for success, as it drives targeted intervention to reduce avoidable hospital and post-acute utilization. This real-time data will enable participants to excel in the Acute Hospital Utilization or Total Per Capita Cost performance measures included within this model.

Bamboo Health supports provider success in Primary Care First and other value-based care models by optimizing encounter efficiency, reducing avoidable utilization, and ensuring patients are receiving critical care when they need it.

For more information on how Bamboo Health can support success in Primary Care First, contact us at [email protected], or complete our contact form.

In February, the Centers for Medicare and Medicaid Services (CMS) released Part II of its 2021 Medicare Advantage and Part D Advance Notice, and the Medicare Advantage and Part D Program Technical Changes proposed rule, which included several updates to the Medicare Advantage Star Rating program. The CMS Star Rating program is used to evaluate the quality of patient care and experience for Medicare beneficiaries, and rates health plans using a five-star system based on their performance against 30+ quality measures, including both clinical HEDIS measures, and survey measures.

Beginning in measurement year 2021, which will impact health plans’ 2023 Star ratings, two additional HEDIS measures will be included for scoring; Transitions of Care and Follow-up after ED Visit for People with Multiple Chronic Conditions. Both measures will be worth one point of health plans’ performances in the Managing Chronic (Long-Term) Conditions domain and will impact their overall ratings on the five-star quality scale. With these new measures, and especially as the Transitions of Care measure is expected to be weighted more heavily in the future, it’s critical that health plans have the tools and resources needed to efficiently monitor members’ care transitions and ensure timely follow-ups.

Transitions of Care Measure

Coordinating care for members following a hospital or ED discharges is critical for health plans in order to avoid unnecessary readmissions and ensure proper care delivery. However, transitions from acute care settings are often subject to poor care collaboration. To overcome these challenges, the Transitions of Care Measure will rate health plans on the percentage of Medicare beneficiaries 18 years and older where following discharge from an inpatient facility, the following criteria were satisfied:

• Notification of Member Admission:
  Health plans will need to provide documentation in members’ medical records of a receipt of notification (via phone, email, fax, EMR, or ADT notification), the day of or day following members’ admissions.
• Receipt of Discharge Information:
  Documentation must be made in members’ medical records with a receipt of discharge information on the day of, or following the member’s discharge. Documentation must include information on the member’s treating provider, procedures and/or treatment(s) provided, diagnosis at discharge, current medication list, testing results, and treatment instructions for ongoing care providers.
• Patient Engagement:
  Organizations must show proof of engagement provided to members in the 30 days following their discharge. Member engagement includes office, at- home, telehealth, or telephonic visits.
• Medication Reconciliation:
  Medication reconciliation must occur and be documented on the day of discharge through 30 days post-discharge (31-day window) by a prescribing practitioner, clinical pharmacist, or registered nurse.

Follow-up After Emergency Department Visit for Patients with Multiple Chronic Conditions Measure

With high-risk patients and those faced with multiple chronic conditions often being at risk for readmission, health plans need to ensure timely and proper follow-ups post-discharge from the ED or hospital. To further support these efforts, health plans will now be measured on the percentage of ED visits for members 18 years and older who have multiple high-risk, chronic conditions, where the members had a follow-up service within 7 days of their ED visit.

• Member eligibility criteria:
  Eligible members must have two or more of the following conditions: COPD and asthma, Alzheimer’s disease and related disorders, chronic kidney disease, depression, heart failure, acute myocardial infarction, atrial fibrillation, and stroke and transient ischemic attack.
• Follow-up services criteria:
  Follow-up services can include outpatient visits and encounters, telehealth and telephonic visits, transitional or complex care management services, case management visits, and behavioral health visits.

How to Prepare for These Changes

With these new measures, health plans should consider their existing performance measures with similar requirements, especially those that require timely follow-ups and close coordination of care. Organizations should determine real-time care coordination solutions that will enable adherence to the timeliness requirements with these two measures, and allow them to monitor member discharges to ensure coordinated follow-ups.

Additionally, organizations should look for solutions that enable close collaboration with community providers and, at the same time, improve quality performance for the Star Rating program and beyond. Additional HEDIS measures that can directly benefit from real-time member admission, discharge, and transfer data to trigger workflows and drive interventions and timely care include: 

• Plan All-Cause Readmissions (also included as a Star Ratings measure)
• Acute Hospital Utilization
• ED Utilization
• Hospitalization for Potentially Preventable Complications
• Follow-Up After Hospitalization for Mental Illness
• Follow-Up After ED Visit for Mental Illness
• Follow-Up after ED Visit for Alcohol and Other Drug Abuse or Dependence
• Prenatal and Postpartum Care

For more information on how to prepare and succeed with the newly-released measures, contact us at [email protected], or complete our contact form.