HCMG LATEST QUESTIONS AND ANSWERS UPDATE: A
MASTERING A+ MATERIAL!
Where do savings come from in Medicare bundled payment programs?
All savings by program design come from post acute care (hospitals are paid prospective
payment for each patient upfront... so all savings come later)
Oncology Care Model
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) is developing new
payment and delivery models designed to improve the effectiveness and efficiency of specialty
care. Among those specialty models is the Oncology Care Model, which aims to provide higher
quality, more highly coordinated oncology care at the same or lower cost to Medicare. Under
the Oncology Care Model (OCM), physician practices have entered into payment arrangements
that include financial and performance accountability for episodes of care surrounding
chemotherapy administration to cancer patients. The Centers for Medicare and Medicaid
Services (CMS) is also partnering with commercial payers in the model. The practices
participating in OCM have committed to providing enhanced services to Medicare beneficiaries
such as care coordination, navigation, and national treatment guidelines for care.
Comprehensive Care for Joint Replacement
Mandatory program (important! most are voluntary but Medicare mandated this program)
All about post acute care, reducing skilled nursing. Institutional post acute care went down...
~800 hospitals in 67 regions received bundled payments for joint replacements --> now 400 in
34 markets
Episode of care begins with hospital admission and ends 90 days post discharge
Covers hospital and physician services
Hospital is also responsible for post-acute care costs
Deliberate oversample of high cost areas
ONLINE DEFINITION
The Comprehensive Care for Joint Replacement (CJR) model aims to support better and more
efficient care for beneficiaries undergoing the most common inpatient surgeries for Medicare
beneficiaries: hip and knee replacements (also called lower extremity joint replacements or
LEJR). This model tests bundled payment and quality measurement for an episode of care
, associated with hip and knee replacements to encourage hospitals, physicians, and post-acute
care providers to work together to improve the quality and coordination of care from the initial
hospitalization through recovery. This model was implemented and modified through notice
and comment rulemaking and the relevant proposed and final rules are linked at the bottom of
this page.
BPCI - Advanced Model
Voluntary model
Single retrospective bundled payment
Expanded to 31 inpatient and 4 outpatient episodes
Modest savings
ONLINE DEFINITION:
The Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model is a new
iteration of the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare
and Medicaid Innovation (Innovation Center) continuing efforts in implementing voluntary
episode payment models. The Model aims to support healthcare providers who invest in
practice innovation and care redesign to better coordinate care and reduce expenditures, while
improving the quality of care for Medicare beneficiaries. BPCI Advanced qualifies as an
Advanced Alternative Payment Model (APM) under the Quality Payment Program.
BPCI-Advanced is defined by following characteristics:
- Voluntary Model
- A single retrospective bundled payment and one risk track, with a 90-day Clinical Episode
duration
- 8 Clinical Episode Service Lines Groups starting Model Year 4 (30 Inpatient, 3 Outpatient and 1
multi-setting Clinical Episode categories)
- Qualifies as an Advanced Alternative Payment Model (AAPM)
- Payment is tied to performance on Quality Measures
- Preliminary Target Prices provided prior to each Model Year
The BPCI Advanced Model aims to encourage clinicians to redesign care delivery by adopting
best practices, reducing variation from standards of care, and providing a clinically appropriate
level of services for patients throughout a Clinical Episode.
BPCI Advanced will operate under a total-cost-of-care concept, in which the total Medicare Fee
for Services (FFS) spending on all items and services furnished to a BPCI Advanced Beneficiary
during the Clinical Episode, including outlier payments, will be part of the Clinical Episode
MASTERING A+ MATERIAL!
Where do savings come from in Medicare bundled payment programs?
All savings by program design come from post acute care (hospitals are paid prospective
payment for each patient upfront... so all savings come later)
Oncology Care Model
The Center for Medicare & Medicaid Innovation (CMS Innovation Center) is developing new
payment and delivery models designed to improve the effectiveness and efficiency of specialty
care. Among those specialty models is the Oncology Care Model, which aims to provide higher
quality, more highly coordinated oncology care at the same or lower cost to Medicare. Under
the Oncology Care Model (OCM), physician practices have entered into payment arrangements
that include financial and performance accountability for episodes of care surrounding
chemotherapy administration to cancer patients. The Centers for Medicare and Medicaid
Services (CMS) is also partnering with commercial payers in the model. The practices
participating in OCM have committed to providing enhanced services to Medicare beneficiaries
such as care coordination, navigation, and national treatment guidelines for care.
Comprehensive Care for Joint Replacement
Mandatory program (important! most are voluntary but Medicare mandated this program)
All about post acute care, reducing skilled nursing. Institutional post acute care went down...
~800 hospitals in 67 regions received bundled payments for joint replacements --> now 400 in
34 markets
Episode of care begins with hospital admission and ends 90 days post discharge
Covers hospital and physician services
Hospital is also responsible for post-acute care costs
Deliberate oversample of high cost areas
ONLINE DEFINITION
The Comprehensive Care for Joint Replacement (CJR) model aims to support better and more
efficient care for beneficiaries undergoing the most common inpatient surgeries for Medicare
beneficiaries: hip and knee replacements (also called lower extremity joint replacements or
LEJR). This model tests bundled payment and quality measurement for an episode of care
, associated with hip and knee replacements to encourage hospitals, physicians, and post-acute
care providers to work together to improve the quality and coordination of care from the initial
hospitalization through recovery. This model was implemented and modified through notice
and comment rulemaking and the relevant proposed and final rules are linked at the bottom of
this page.
BPCI - Advanced Model
Voluntary model
Single retrospective bundled payment
Expanded to 31 inpatient and 4 outpatient episodes
Modest savings
ONLINE DEFINITION:
The Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model is a new
iteration of the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare
and Medicaid Innovation (Innovation Center) continuing efforts in implementing voluntary
episode payment models. The Model aims to support healthcare providers who invest in
practice innovation and care redesign to better coordinate care and reduce expenditures, while
improving the quality of care for Medicare beneficiaries. BPCI Advanced qualifies as an
Advanced Alternative Payment Model (APM) under the Quality Payment Program.
BPCI-Advanced is defined by following characteristics:
- Voluntary Model
- A single retrospective bundled payment and one risk track, with a 90-day Clinical Episode
duration
- 8 Clinical Episode Service Lines Groups starting Model Year 4 (30 Inpatient, 3 Outpatient and 1
multi-setting Clinical Episode categories)
- Qualifies as an Advanced Alternative Payment Model (AAPM)
- Payment is tied to performance on Quality Measures
- Preliminary Target Prices provided prior to each Model Year
The BPCI Advanced Model aims to encourage clinicians to redesign care delivery by adopting
best practices, reducing variation from standards of care, and providing a clinically appropriate
level of services for patients throughout a Clinical Episode.
BPCI Advanced will operate under a total-cost-of-care concept, in which the total Medicare Fee
for Services (FFS) spending on all items and services furnished to a BPCI Advanced Beneficiary
during the Clinical Episode, including outlier payments, will be part of the Clinical Episode
