Elias Matsakis is a Partner in Holland & Knight's Chicago office
Co-authored by Mya Strauss
Centers for Medicare & Medicaid Services (CMS) has published the list of 832 Acute Care Hospitals and 715 Physician Group Practices which will be participating in the Bundled Payments for Care Improvement – Advanced (BPCI Advanced) Model which will run from Oct. 1, 2018 through Dec. 31, 2023, as well as the list of convener participants. Convener participants bring together multiple downstream entities, and bear and apportion financial risk under the model. This voluntary advanced payment model provides a single retrospective bundled payment as to of 32 bundled clinical episodes (29 inpatient/3 outpatient) with payment tied to performance on quality measures. Participants selected to participate in BPCI Advanced beginning on Oct. 1, 2018, must commit to be held accountable for one or more Clinical Episodes and may not add or drop such Clinical Episodes until Jan. 1, 2020.
Annually, participants receive a preliminary target price for each performance period. Major Joint Replacement lower extremity, congestive heart failure and sepsis topped the list of episodes chosen by the hospitals and physician groups for BPCI Advanced. Reconciliation will be made semiannually via a comparison of the aggregate Medicare Fee Service expenditures for all items and services in the 90-day period following inpatient admission or the start of the outpatient procedure against the target price for those services. It is subject to a 20 percent upward or downward stop-loss/stop-gain limit.
Seven quality measures have been selected. Two of them—All-cause Hospital Readmission Measure (NQF#1789) and Advanced Care Plan (NQF 0326)—are applicable to all 90-day episodes. The remainder are episode specific. The list of providers and their clinical episode selections and the list of more than 10,000 skilled nursing facilities that received 3-day waivers under the program can be found at CMS.gov.
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