CMS launches advanced APM focused on bundled payments

Dr. Michael E. Nelson

Michael E. Nelson, MD, FCCP, comments: While this may not be a panacea for all of the ills of our expensive but broken healthcare system, it is heartening to see CMS at least propose new models of healthcare delivery. The move away from a fee-for-service model was inevitable for government-funded health care given the ever-increasing costs coupled with the dismal rankings when compared with other nations. The United States spends more than any other nation but is 37th in the WHO health-care performance ratings ¬ ouch. Unfortunately, as long as healthcare remains a political football, change for the better may be miserably slow.


The Centers for Medicare & Medicaid Services is launching a new voluntary bundled payment demonstration project that for the first time will qualify as an advanced alternative payment model under the Quality Payment Program.

The Bundled Payments for Care Improvement Advanced (BPCI Advanced) “builds on the earlier success of bundled payment models and is an important step in the move away from fee-for-service and towards paying for value,” CMS Administrator Seema Verma said in a statement. “Under this model, providers will have an incentive to deliver high-quality care.”

Medicare-certified acute care hospitals and physician group practices are eligible to take part in the BPCI Advanced, according to Medicare documentation. They will be categorized either as “conveners” – entities that bring together multiple parties for the purpose of coordinating care, as well as apportioning financial risks – or as “nonconveners” – those who bear financial risk for themselves only.

Both categories of participants may enter into agreements with individual physicians and nonphysician providers to furnish care under the bundled payment model.

The program will provide a single retrospective payment and one risk track, with a 90-day clinical episode duration. It will cover 29 in-patient episodes and three outpatient clinical episodes. Payment will be tied to performance on quality measures.

The 29 in-patient clinical episodes cover a range of conditions, including liver disorders (excluding malignancy, cirrhosis, and alcoholic hepatitis); various cardiac conditions; chronic obstructive pulmonary disease, bronchitis, and asthma; spinal fusion; joint replacements; femur, hip, or pelvis fractures; gastrointestinal hemorrhage or obstruction; renal failure; sepsis; simple pneumonia and respiratory infections; stroke; and urinary tract infections.

The three outpatient clinical episodes include percutaneous coronary intervention, cardiac defibrillator implantation, and back and neck surgery except spinal fusion.

Seven quality measures will be tracked as part of the payment. For all clinical episodes, measurement of all-cause hospital readmissions and advance care plan will be required.

The other five will be applied to the payment when appropriate, as follows:

  • 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 indicators.

CMS has scheduled an open-door forum for those interested in participating in BPCI Advanced on Jan. 30.

Applications for participation will be accepted through March 12.

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