What is Bundled Payment & BPCI?

 The Centers for Medicare & Medicaid Services (CMS), through the Center for Medicare and Medicaid Innovation (CMMI), and the other stakeholders are actively developing cost-cutting initiatives to curb unsustainable healthcare costs. In this context, CMS has created a Bundled Payment Program known as BPCI Advanced.

A Bundled Payment combines or bundles Medicare reimbursements to healthcare institutions for several types of medical services supplied to the patient over a specific time period. Bundled-payment programs reimburse hospitals, clinicians, post-acute practitioners, and other care professionals (for home healthcare, diagnostics, medical devices) for a specific duration of intervention. The BPCI Advanced might involve a hospital inpatient hospitalization or an outpatient procedure.

Synopsis of the BPCI Model

The BPCI Advanced model allows health professionals to receive incentive payments by cutting healthcare spending while preserving the quality of coordinated care. The following aspects distinguish the BPCI Program from previous bundling initiatives:

• It is crafted on the basis of Voluntary Service.
• It is a retrospective bundled payment and a specific risk profile, with a Medical Period length of 90 days.
• Starting with Model Year 4, there will be 8 Clinical Episode Service Lines Groups (30 Inpatient, 3 Outpatient and 1 multi-setting Clinical Episode category)
• It qualifies as an Advanced Alternative Payment Model (AAPM)
• Payment is linked to performance on Quality Measures.
• Prior to each Model Year, Preliminary Target Prices are published.
• Physician Group Practices (PGPs) may be the primary stakeholder and in-power of allocating financial risk among other stakeholders.

How does BPCI Advanced Works?

The program meets the Advanced Alternative Payment Model criteria under the Medicare Access and CHIP Reauthorization Act of 2015. (MACRA). Healthcare professionals are not required to submit Merit-based Incentive Payment System (MIPS) reports for the patients. Outpatient procedures are currently responsible for three Clinical Episodes (CE), including percutaneous coronary intervention, cardiac defibrillator, and back and neck procedures.

BPCI Advanced will perform on the basic principle of total-cost-of-care, which means that the total Medicare Fee for Services (FFS) spent on all products and services provided to a BPCI Advanced Beneficiary during the CE, including outlier reimbursements, will be included in the CE spending for uses of the Target Price and settlement estimations, except if explicitly excluded.

BPCI & Risk Adjustment Coefficients

The risk adjustment coefficients will not be recalculated during the Performance Cycle. Instead, the risk adjustment factors from the baseline period (4 years) will be re-utilized to the actual case mix that took place during the Performance Cycle.