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New bundled payment model from CMS meets advanced APM standards

Providers will find a new entry into the world of advanced alternative payment models (APM) after CMS announced the Bundled Payments for Care Improvement (BPCI) Advanced program, which will reward providers on the basis of their cost-containment scores for 32 distinct episodes of care.
The BPCI Advanced model, which kicks off Oct. 1, 2018, is heavy on the inpatient side of things, with only a few options available to outpatient providers. The model offers 29 episodes for inpatient care and just three outpatient-based clinical episodes. The outpatient episodes are:
  • Percutaneous coronary intervention.
  • Cardiac defibrillator.
  • Back and neck except spinal fusion.
For outpatient episodes under the BPCI Advanced model, the episode begins at the start of the outpatient procedure, or what CMS calls the "anchor procedure," and continues until 90 days after the procedure. That may sound familiar to outpatient providers: the length of time mimics the standard 90-day global surgical period for major procedures.
Other episodes eligible on the inpatient side include acute myocardial infarction, double lower-extremity joint replacement, stroke and others.
Practices that participate in the program will be eligible for pay bonuses if total costs accrued during the 90-day period are less than the target price set by CMS. But be warned: if you come in over the target price, you'll be on the hook to cover a "repayment amount." Target prices will be released in advance of the performance period, said CMS.
CMS will assess practices on a range of up to seven quality measures. Two quality measures -- the all-cause readmission rate and advanced care plan -- will apply to all clinical episodes, while the remaining measures will apply only to select cases. Providers that opt to join the BPCI Advanced model must commit to at least one clinical episode by Oct. 1 and cannot shift their preferences until Jan. 1, 2020.
Providers that opt to participate will qualify as an advanced APM under the merit-based incentive payment system (MIPS), which would excuse them from MIPS reporting.
CMS said that holding providers accountable for overall costs "improves coordination and creates incentives for health care providers to deliver care more efficiently" and may motivate providers to "consider the financial implications of their treatment decisions."
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