Kellyn A Pearson, RN, MSN, Learning Community Manager, Department of Family Medicine Matt Keelin, TCPI Program Director, State Innovation Model ...
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Kellyn A Pearson, RN, MSN, Learning Community Manager, Department of Family Medicine Matt Keelin, TCPI Program Director, State Innovation Model (SIM) Office Andrew Forbes, TCPI Data and Policy Analyst, State Innovation Model (SIM) Office 1
Webinar Outline
Defining Payment and
Model Who Can
Clinical Pricing
Overview Participate
Episodes Methodology
Quality
How to Apply Resources
Measures
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BPCI Advanced is Different Than BPCI
• Streamlined design
– One model, 90 day episode period
– Single risk track
– Inpatient and Outpatient episodes
– Preliminary target prices provided in advance
– Payment tied to performance on quality measures
• Greater focus on physician engagement and learning
• Designed as an Advanced APM under the Quality Payment
Program
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Model Overview BPCI-Advanced is defined by following characteristics: –Voluntary Model –A single retrospective bundled payment and one risk track, with a 90- day Clinical Episode duration –33 Inpatient Clinical Episodes starting Model Year 3 –4 Outpatient Clinical Episodes starting Model Year 3 –Qualifies as an Advanced Alternative Payment Model (AAPM) –Payment is tied to performance on Quality Measures –Preliminary Target Prices provided prior to each Model Year
Applications Due; June 24, 2019
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Physicians • Physicians are ideally positioned to direct high-value, patient- centered care, and they are crucial to the success of BPCI Advanced. The model emphasizes specialty physician engagement and provides resources to facilitate peer-to-peer learning. • BPCI Advanced - Why Participate? (PDF) • Physician-Focused Materials
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Participants Convener Participants is a type of Participant that brings together at least one entity referred to as “Downstream Episode Initiators” (Downstream EIs)—which must be either Acute Care Hospitals (ACHs) or Physician Group Practices (PGPs)—to participate in BPCI Advanced, facilitate coordination among them, and bear and apportion financial risks. Convener Participants enter into agreements with the EIs, whereby EIs agree to participate in BPCI Advanced and comply with all applicable Model requirements. • Eligible entities that are Medicare-enrolled providers or suppliers • Eligible entities that are not enrolled in Medicare • Acute Care Hospitals (ACHs) • Physician Group Practices (PGPs) Non-Convener Participant is the Episode Initiator (EI) that bears financial risk only for itself and does not have any Downstream EIs. • Acute Care Hospitals (ACHs) • Physician Group Practices (PGPs)
Participants May Work With a Convener
A Convener is a Medicare enrolled provider or supplier or an entity that is not enrolled in
Medicare.
Conveners may:
• Facilitate participation by smaller PGPs or ACHs
• Provide data and analytic feedback
• Offer logistical and operational support
• Bear financial risk to CMS under the Model
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33 Inpatient (IP) Clinical Episodes
Spine, Bone, and Joint Episodes Kidney
• Back & neck except spinal fusion • Renal failure
• Spinal fusion (non-cervical)
• Cervical spinal fusion
• Combined anterior posterior spinal fusion Infectious Diseases
• Fractures of the femur and hip or pelvis • Cellulitis
• Hip & femur procedures except major joint • Sepsis
• Lower extremity/humerus procedure except hip, foot, • Urinary tract infection
femur
• Major joint replacement of the lower extremity*
• Major joint replacement of the upper extremity Neurology
• Double joint replacement of the lower extremity • Stroke
• Seizures **
*This is a multi-setting Clinical Episode category. Total Knee
Arthroplasty (TKA) procedures can trigger episodes in both inpatient and
** New in MY3
outpatient settings
1733 Inpatient (IP) Clinical Episodes
4 Outpatient (OP) Clinical Episodes
https://innovation.cms.gov/initiatives/bpci-advanced/#episodes
Cardiac Episodes Pulmonary Episodes
• Transcatheter Aortic Valve Replacement **
• Acute myocardial infarction • Simple pneumonia and
• Cardiac arrhythmia respiratory infections
• Cardiac defibrillator • COPD, bronchitis, asthma
• Cardiac valve
• Pacemaker
• Percutaneous coronary intervention Outpatient
• Coronary artery bypass graft • Percutaneous Coronary
• Congestive heart failure Intervention (PCI)
• Cardiac Defibrillator
Gastrointestinal Episodes
• Bariatric Surgery**
• Back & Neck Except Spinal Fusion
• Inflammatory Bowel Disease**
• Major bowel procedure • Major joint replacement of the
lower extremity (MJRLE)*
• Gastrointestinal hemorrhage
*This is a multi-setting Clinical Episode category.
• Gastrointestinal obstruction Total Knee Arthroplasty (TKA) procedures can
• Disorders of the liver excluding malignancy, cirrhosis, trigger episodes in both inpatient and outpatient
settings
alcoholic hepatitis (New Episode for BPCI Advanced) 18Services Included in the Clinical Episode
• IP or OP hospital services that • Clinical laboratory services
comprise the Anchor Stay or Anchor • Durable medical equipment
Procedure (respectively) (DME)
• Physicians’ services • Part B drugs
• Other hospital OP services
• IP hospital readmission services
• Long-term care hospital (LTCH) services
• Hospice services
• Inpatient rehabilitation facility (IRF)
services
• Skilled nursing facility (SNF) services
• Home health agency (HHA) services
19Precedence, and Overlap Precedence: • Overlapping Episode Initiators: – First priority to attending physician – Second priority to operating physician – Third priority is the hospital where the anchor services were performed BPCI-A and Medicare ACOs: • Excluded Models: – Next Generation ACOs – MSSP Track 3 ACOs • Included Models: – MSSP Tracks 1, 1+, and 2 Note: CMS has yet to release information on the overlap between the new Pathways to Success ACO program and BPCI-A
Quality Measures
Will include claims-based Additional measures with
measures through 2020 varying reporting
mechanisms may be
added in the future
21Quality Measures CMS has selected seven Administrative Quality Measures for the BPCI Advanced Model Years 1 & 2 (2018 & 2019). Three required for all Clinical Episodes –All-cause Hospital Readmission Measure –Advance Care Plan –CMS Patient Safety Indicators • Four quality measures will only apply to select Clinical Episodes. • BPCI Advanced: Quality Measures Fact Sheets
Quality Measures Correlation to Clinical Episodes – Model Years 1 & 2 (PDF)
BPCI Advanced: Pricing • Pricing is based on a four year historical period: October 1, 2014 – September 30, 2018 • The price is specific to the facility participant or the facility in which the participant treats patients. • Price adjustment mechanisms: – Participant’s actual patient case mix – EI’s efficiency relative to its peers – Regional spending trends • CMS builds a 3% discount into the pricing model. • Clinical episode pricing for Model Year 3 to be delivered by CMS in September 2019.
BPCI Advanced Model
Pricing Methodology and Payment
• Retrospective bundled payment approach
–CMS reconciles all non-excluded Medicare FFS expenditures for a
Clinical Episode against a Target Price for that Clinical Episode.
• CMS may make payments to Model Participants or
• Model Participants may owe a payment to CMS
–Occur at the Episode Initiator (EI) level
• Target Price calculations,
• Reconciliation calculations
• Attribution of Clinical Episodes to Participants
CMS has developed a large number of technical resources providing
guidance Participants Resources web page.Reconciliation and Gainsharing Reconciliation • Semi-annual reconciliation • Stop-loss threshold capped at +/- 20% at EI level • Payments can be reduced by 10% based on adherence to quality measures Gainsharing • ACOs can be active partners in care redesign and share the rewards from improving value for patients. • Participants may also share risk and reward with clinicians, including nurse practitioners and primary care groups. • NPRA sharing partners must participate in quality improvement activities: – Implementing care redesign – Reporting on quality measures – Use of Certified Electronic Health Records – Attesting to minimum of four MIPS improvement activities – Other activities as specified by CMS Source: Program data from CMS BPCI Advanced Participants file as of March 2019; CMS Model Overview Fact Sheet – Model Year 3 (MY3), released April 24, 2019.
BPCI Advanced: Advanced APM Status BPCI-A meets the criteria to qualify as an Advanced APM to achieve 5% incentive payments if thresholds are met. APM Criteria • Participants must bear risk for monetary losses of more than a nominal amount. • Participants must use Certified Electronic Health Record Technology (CEHRT). • Payment must be linked to quality measures comparable to Merit-Based Incentive Payment System (MIPS) quality measures. Advanced APM Thresholds (Performance Year 2019): • Must receive at least 50% of your Medicare Part B payments OR see at least 35% of Medicare patients through an Advanced APM entity. • 75% of practices within the Advanced APM entity need to use certified EHR Technology.
Characteristics of High Performers
Partnership to promote care coordination & data sharing
Efficient and appropriate staffing models
Patient identification and risk stratification
Effective clinical and financial management
Patient & family engagement throughout care continuum
Data driven program management
Continuous quality improvementStrategies for Success in Population Based APMs
Know your contract Know your patients
• How will you make money? How will you • Who is the target population? How will
lose money? you identify them?
• How are providers incentivized? • What are risks (medical and non-medical)
• How will the acuity of your population be that need to be addressed for performance?
taken into account? • How will you manage and ensure
• Are there exclusions? Risk corridors? coordinated care across the continuum?
Stop Loss?
Know your data Know your team
• What are your cost drivers? What will it • Create a plan for success
take to impact them? • How will you engage your team in this
• What are your quality metrics? How are work?
you currently performing? • How will you coordinate with other
• How will you track your progress? providers / service providers?
• What changes need to occur to optimize
performance for this contract?Applicants Will Receive Data in Advance
• CMS will provide preliminary target prices to applicants in Sept 2019
• Applicants who submit a Data Request and Attestation form
– Three years of aggregate (summary) and/or raw (beneficiary line-level) Historical Claims data
for the Medicare beneficiaries who would have been included in a Clinical Episode and
attributed to the applicantClinical Episode Selection • Participants will enter into an agreement with CMS – May be renewed annually – Commits to selected Clinical Episodes until the start of the following Agreement Term • Episode selections must be submitted to CMS by November 1, 2019
Application Roadmap –Model Year 3 (MY3)
35BPCI Advanced: Applicant Resources • Application Period for Model Year 3 • The application period for the second cohort is currently open and will close on June 24, 2019. At this time, CMS is not planning any additional application opportunities for the Model. • Application Roadmap MY3 (PDF) • Application Process FAQ (PDF)
How To Apply • CMS will only accept applications via the BPCI Advanced Application Portal / https://app1.innovation.cms.gov/bpciadvancedapp. • BPCI Advanced Application Portal; an online platform that allows Applicants to: –Apply to the BPCI Advanced model –Edit or Delete In-Progress Applications –Clone Submitted Applications –View and Download Submitted Applications and Data Request and Attestation (DRA) forms. • How to Contact the BPCI Advanced Team –If you have questions regarding the Model, you can contact the BPCI Advanced team by emailing BPCIAdvanced@cms.hhs.gov.
New Applicants • Applicant Guide - MY3 (PDF) • Application Template MY3 (PDF) • Application Attachment - Participating Organizations Template MY3 (XLS) • Application Portal Walkthrough - MY3 (PDF)
General Information for Model Year 3 (2020) • Model Overview Fact Sheet - MY3 (PDF) • Webcast: Model Overview MY3: Audio (mp4) | Slides (PDF) | Transcript (PDF) • Application Process FAQ (PDF)
FAQs by Topic • General FAQs (PDF) • Application Process FAQ (PDF)
Physician-Focused Materials • BPCI Advanced - Why Participate? (PDF) • Physician Fact Sheet (PDF) • Physician Frequently Asked Questions (PDF) • Patient Experience in FFS vs. Bundled Payments - Cardiology (mp4) • Patient Experience in FFS vs. Bundled Payments – Surgical (mp4) • Webcast: Conceptual Overview (2018) - Audio (mp4) | Slides (PDF) | Transcript (PDF) • Webcast: Operationalizing BPCI (2018) - Audio (mp4) | Slides (PDF) | Transcript (PDF)
Additional Information • Attribution-Eligible Beneficiaries under the Quality Payment Program Fact Sheet (PDF) • BPCI Advanced Participants - Model Year 2 (XLS) (updated 03/15/19) • Bundled Payments for Care Improvement Toolkit (PDF) • Episode Initiators and Clinical Episode Selections - Model Year 2 (XLS) (updated 03/15/19) • Model Overview Fact Sheet – MY3 (PDF) • SNF Waiver List (XLS) (April - June 2019) (updated 04/01/19) • Mutual Amendment Announcement (PDF) • Webcast: Model Overview MY3: Audio (MP4) | Slides (PDF) | Transcript (PDF) • Archived Materials
Contact Information Also welcome to contact us directly if you have questions: Allyson.Gottsman@UCDenver.edu Matthew.Keelin@state.co.us Kellyn.Pearson@UCDenver.edu
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