CMS Woos Providers With More Gains, Less Risk in Bundled Payments

Gregory A. Freeman, January 22, 2018

CMS recently announced a new version of its bundled payments program, with more incentives to participate. Doctors can qualify for higher payments under MACRA, an advantage for hospitals looking to affiliate with physician groups.

A new bundled payments program should draw more hospitals in with a structure that limits potential financial loss while increasing the potential gains. The program follows promises by the government that it would incentivize both highly efficient and less-efficient providers with its new pricing methodology.

The new Bundled Payments for Care Improvement Advanced (BPCI Advanced) program from the Centers for Medicare & Medicaid Services is a second-generation version of the BPCI program. BPCI Advanced is a voluntary program that offers a single retrospective bundled payment covering services within a 90-day clinical episode.

Program overview

A clinical episode begins with an inpatient admission for an inpatient procedure or the start of the outpatient procedure, continuing for 90 days after discharge or the procedure.

Participants may participate in up to 29 inpatient clinical episodes and three outpatient clinical episodes (percutaneous coronary intervention, cardiac defibrillator, and back and neck except spinal fusion). CMS provides target prices in advance, measured against the total Medicare fee-for-service spending and services during the clinical episodes.

CMS has refined the program to make bundled payments more appealing to healthcare providers, says Keely Macmillan, general manager of BPCI with Archway Health, which assists healthcare providers with bundled payments.

"Providers should be encouraged about the new BPCI Advanced program, as it provides more opportunities for upside revenue. CMS will now provide a limit to how much downside a provider can be responsible for by providing a 20% stop-loss of their total program size," she says. "Full target pricing details are still forthcoming from CMS, but we expect the new pricing model to be more inclusive."

BPCI Advanced also comes with a new Episode Initiator focus. BPCI Advanced will qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program adopted as part of the Medicare Access and CHIP Reauthorization Act (MACRA). Physicians participating in BPCI Advanced may earn MACRA's Advanced APM incentive payments because they take on financial risk.

Gregory A. Freeman

Gregory A. Freeman is a contributing writer.

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