CONCEPTUAL OVERVIEW JANUARY 2018
Intr troducti tion Stev eve e Farmer er, M MD, FACC, F FASE • Medical Officer • CMS Innovation Center • Practicing Cardiologist 2
Webcas ast Ou Outline The CMS Innovation Center and BPCI Advanced • Clinical Concept • BPCI Advanced Model Overview • Model Development • Participation Requirements • Strategies for Success • Why Should I Participate in the Model? • CMS Innovation Center Partnership • Summary • 3
INTROD ODUCTION ON The CMS Innovation Center and BPCI Advanced 4
The CM he CMS I Inn nnovation Cen Center er • As part of the Center for Medicare and Medicaid Services (CMS), the CMS Innovation Center provides national leadership in the transition from volume to value • The center tests innovative service and delivery models that reduce costs while preserving or enhancing quality • Guiding principles o Patient centered care o Provider choice and incentives o Choice and competition in the market o Transparent model design and evaluation 5
Model Sce cenarios f for S Succe ccess 1 Quality Cost 2 Quality Cost 3 Best Case Quality Cost 6
BPC PCI A Advanced T Tests a a Different A Approach ch to P Payment A bundl bundled c clini nical e epi pisode de links physician, hospital, and post-acute care payments to quality and cost Participants may earn addi dditio ional pay ayments f fro rom CMS, but may owe money back to CMS, if costs are higher than expected 7
CLINICAL C L CON ONCEP EPT 8
Patients O Often Ex Experience a a Fragmented Healthcare S System Status Quo: Fee for Service (FFS) Under FFS, healthcare can be challenging to navigate Providers often treat patients • with incomplete information. Patients often receive • conflicting advice. Providers acting independently hold little accountability for cost or outcomes of care 9
Fe Fee-fo for-Service (FF (FFS): H Hospitalization Hospit Ho ital Hazard rd Pat atient E Exper erien ence – X – Ho Hospit italis list 10
FFS: H Hospital al D Dischar arge Hazard rd Pa Patient Skille lled Nursin ing F Facilit ility Ho Hospit italis list (SNF) F) Patien ent t Exper erien ence e 11
FF FFS: S SNF Patie ient’s Ho Home SNF T F Team SNF S F Stay Pat atient E Exper erien ence 12
FFS: Primary C Care Ph Physician ( (PC PCP) P) a and Cardiol ologi ogist Pat atient E Exper erien ence Hazard rd PCP CP Cardio iolo logis ist 13
FFS Ex Experience: S Summary Hospitalist CARE GAP SNF Team Patient CARE GAP Cardiologist 14
Bundled C Clinical Ep Episodes: A New ew C Concep ept • BPCI Advanced requires new thinking • Participants must now coordinate the entire episode FFS Bundled Clinical Episode Ho Hospit ital Ho Hospit ital SNF Patie ient’s Ho Home Cardio iolo logis ist PCP CP 15
Clini Cl nical Epi pisodes es Be Better er R Reflec ect H How Patients Ex Experience ce C Care Shifts emphasis from indi ndividu idual s servic ices Establishes an towards a coordinated cli linical e l epis isode “accoun untable ble pa party” Clinical episodes are assessed on the qua quality a and nd cost of care 16
Clinical Ep Episode: B Bundled Payment Ex Experience Hosp spitalist a and P nd PCP The S he SNF F Team Patien ent’s C Cardi diologist 17
BPCI A ADVANCED ED M MOD ODEL EL OVER ERVIEW EW 18
BPC PCI A Advanced B Builds o on Ex Experience ce Evide dence Fr From: Commercial payer models • Centers for Medicare and Medicaid Services (CMS) • CMS Innovation Center models • Stakeholde lder I Input nput: Stable target prices provided in advance • Performance assessments account for patient and • provider characteristics 19
BPC PCI A Advanced i is Different T Than B BPC PCI • Streamline ined de design o One model, 90 day episode period o Single risk track o Inpatient and Outpatient episodes o Preliminary target prices provided in advance o Payment tied to performance on quality measures • Greater focus on ph physic icia ian n eng ngagement a and l nd learni ning ng • Designed as an Advanc nced A d APM under the Quality Payment Program 20
Who L Leads Clinical Ep Episodes? Physician Group Acute Care Hospitals Practices (PGPs) (ACHs) 21
Participants M May Work W With a a Convener A Con onvener is a a Med edicare en enrolle led p provid ider or or s supplie lier or or an en entit ity t that is n not ot en enroll lled i in M Med edicare. Conveners m 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 22
29 I Inpatient ( (IP) P) Clinical Ep Episodes, Cont ntinued Spine, Bone, and J Joint E Episodes Kidne dney Renal failure • Back & neck except spinal fusion • • Spinal fusion (non-cervical) • Cervical spinal fusion • Combined anterior posterior spinal fusion Inf nfec ectious D s Disea eases es • Fractures of the femur and hip or pelvis • Cellulitis • Hip & femur procedures except major joint • Sepsis • Lower extremity/humerus procedure • Urinary tract infection except hip, foot, femur • Major joint replacement of the lower extremity • Major joint replacement of the upper Neurolog ology y extremity Stroke • • Double joint replacement of the lower extremity 23
29 I Inpatient ( (IP) P) Clinical Ep Episodes Cardi diac E Epi piso sodes es Pu Pulmon onary E y Episod odes • Acute myocardial infarction • Simple pneumonia • Cardiac arrhythmia and respiratory • Cardiac defibrillator infections • Cardiac valve • COPD, bronchitis, • Pacemaker asthma • Percutaneous coronary intervention • Coronary artery bypass graft • Congestive heart failure Gastrointes estinal E Episo sodes es • Major bowel procedure • Gastrointestinal hemorrhage • Gastrointestinal obstruction • Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis (New Episode for BPCI Advanced) 24
3 Outpatient ( (OP) P) C Clinical Ep Episodes • Percutaneous Coronary Intervention (PCI) • Cardiac Defibrillator • Back & Neck Except Spinal Fusion 25
Hospital al M Medicine & 11 S Special alties Represen ented ed Cardiolog iology E y Episod odes: Kidne dney E Episode des Nephrology • Cardiology • • Cardiac Surgery Spin ine, B Bon one, J Join oint Gastrointes estinal E Episo sodes: es: Epi piso sodes des • Gastroenterology Orthopedics • General Surgery • Neurosurgery • Colorectal surgery • Neurolog ology E y Episod odes Pulmon Pu onary a y and I Infectiou ious Disea seases E ses Epi piso sodes: es: Neurology • • Pulmonary • Critical Care 26
How D Does BPC PCI A Advanced W Work? Clinical episode triggered by either an inpatient hospital stay (Anchor Stay) or outpatient procedure (Anchor Procedure) Clinical episode attributed to PGP or ACH Care provided under standard FFS payments At the end of each performance period, quality and cost performance are assessed 27
Clinical Ep Episode L Length IP Cl Clinical Ep Episode: : Anchor Stay Anchor + 90 days beginning the 90 Days EPISODE Stay day of discharge OP Cl Clinical Ep Episode: : Anchor Procedure + 90 days beginning on the Anchor 90 Days EPISODE day of completion of the Stay outpatient procedure 28
Servi vice ces I Incl cluded i in the Clinical Ep 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 29
Service-level E Exclusions fr from th the Clin linic ical E Epis isode Part rt B B servi vice ces: Blanket e exclusions: • Excluded only if incurred • Blood clotting factors to during a excluded ACH control bleeding for hemophilia patients admission or readmissions • BPCI Advanced will not follow • New technology add-on the clinically related criteria payments under the IPPS guiding Part B exclusions used • Payments for items and in BPCI services with pass-through payment status under the OPPS 30
Acut ute Car e Care e Hospital ( (ACH CH) Benc ) Benchm hmark k Pr Price The Hospi pital’s B Benc nchmark P Price accounts for three central factors: Patient case-mix 1. Patterns of spending relative to the ACHs peer group 2. Historic Medicare FFS expenditures efficiency in resource use specific 3. t o the ACHs Baseline Period 31
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