CMS Revises BPCI-A & Announces Transition to Mandatory Participation

Thoughtware Alert Sep 28, 2020
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With more than 1,700 participants, the Bundled Payments for Care Improvement Advanced (BPCI-A) program is one of the largest value-based payment initiatives launched by CMS. The program has evolved significantly since its inception in 2013, but the primary focus of improving quality and reducing costs for Medicare beneficiaries has remained constant.

  • 2013 BPCI (Models 1 to 4), Voluntary 
  • 2016 Comprehensive Care for Joint Replacement, Mandatory 
  • 2018 BPCI-A, Voluntary 
  • 2021 BPCI-A Revisions 
  • 2024 BPCI-A, Mandatory*

On September 10, Deputy Administrator and Director for CMS’ Center for Medicare & Medicaid Innovation (CMMI) Brad Smith announced to BPCI-A participants that significant changes are planned for model year four, which begins January 1, 2021. The two most notable changes include:

  • Target price changes – CMMI paid $567 million in reconciliation payments to participants in the program’s first two years. Unless target prices are adjusted to use a new realized trending methodology, CMS is estimating a $2 billion loss over the program’s duration. Participants should be prepared for lower target prices in calendar-year 2021 and model financial implications.  
  • A more inclusive episode grouping methodology – Rather than creating clinical episodes from discrete DRG groupings (such as Sepsis, which contains DRG 870, 871, and 872), a broader grouping methodology known as clinical episode service line groups will be used. Under this system, a participant would be responsible for an entire service line. For example, CMS would group the following clinical episodes under a single service line known as “Medical and Critical Care”: Cellulitis, COPD, Bronchitis, Asthma, Renal Failure, Sepsis, Simple Pneumonia and Respiratory Infections, and UTI.  

In addition to these changes, Smith issued a shot across the bow when he announced CMS is planning to accelerate efforts on new bundled payment models and anticipates launching a mandatory model at the completion of BPCI-A.   

“By being mandatory, we are optimistic this future model will mitigate many of the selection effects we have seen in both BPCI and BPCI Advanced,” Smith noted in his email to BPCI participants on September 10, 2020.“Given the lessons we have learned from bundled payments over the past eight years, we view a mandatory model as the logical next step on our journey towards value-based care.”

If you have questions regarding the BPCI-A program, reach out to your BKD Trusted Advisor™ or submit the Contact Us form below.

*Anticipated start date per communication from CMS CMMI Deputy Director Brad Smith in September 10, 2020, email to BPCI-A participants.

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