Continuing its move toward basing reimbursement on quality, the Centers for Medicare & Medicaid Services (CMS) announced a new voluntary bundled payment model that starts Oct. 1 and ties payment to participants’ performance on quality measures.
The Bundled Payments for Care Improvement Advanced program “builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and toward paying for value. Under this model, providers will have an incentive to deliver efficient, high-quality care,” says CMS administrator Seema Verma.
The move came just weeks after CMS canceled the mandatory hip fracture and cardiac bundled payment programs, which were scheduled to begin on Jan. 1, 2018, and continue through Dec. 31, 2023.
The new program includes 29 inpatient clinical episodes and three outpatient clinical episodes. The episode of care begins at the start of an inpatient or the start of an outpatient procedure and ends 90 days later. Participants will receive regular Medicare fee-for-service payments for care.
The program will evaluate providers’ performance retrospectively every six months, comparing the total cost of care for the clinical episode to a target price that will be provided before the performance period begins. Payment for participants also is tied to performance on quality measures. CMS will use the performance and quality data to determine whether the provider will receive a bonus or is required to repay CMS for part of the reimbursement.
CMS has designated seven quality measures that will be used in the program. The all-cause hospital readmission measure and advance care plan measure will be required for all clinical episodes. The other five will apply only to select clinical episodes. They are perioperative care; selection of prophylactic antibiotic; first- or second-generation cephalosporin; hospital-level risk-standardized complication rate following elective primary total hip arthroplasty and/or total knee arthroplasty; hospital 30-day, all-cause, risk-standardized mortality rate following coronary artery bypass graft surgery; excess days in acute care after hospitalization for acute myocardial infarction; and AHRQ Patient Safety Quality Indicators.
The 29 inpatient clinical episodes are the following:
• acute myocardial infarction;
• back and neck, except spinal fusion;
• cardiac arrhythmia;
• cardiac defibrillator;
• cardiac valve;
• cellulitis;
• cervical spinal fusion;
• chronic obstructive pulmonary disorder, bronchitis, and asthma;
• combined anterior/posterior spinal fusion;
• congestive heart failure;
• coronary artery bypass graft;
• disorders of the liver, excluding malignancy, cirrhosis, and alcoholic hepatitis;
• double joint replacement of the lower extremity;
• fractures of the femur and hip or pelvis;
• gastrointestinal hemorrhage;
• gastrointestinal obstruction;
• hip and femur procedures except major joint;
• lower extremity/humerus procedure except hip, foot, femur;
• major bowel procedure;
• major joint replacement of lower extremity;
• major joint replacement of upper extremity;
• pacemaker;
• percutaneous coronary intervention;
• renal failure;
• sepsis;
• simple pneumonia and respiratory infections;
• spinal fusion (non-cervical);
• stroke;
• urinary tract infection.
The three outpatient clinical episodes are:
• percutaneous coronary intervention;
• cardiac defibrillator;
• back and neck, except spinal fusion.
Continuing its move toward basing reimbursement on quality, the Centers for Medicare & Medicaid Services announced a new voluntary bundled payment model that starts Oct. 1 and ties payment to participants’ performance on quality measures.
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