Updates to Model Year 4 of the Bundled Payments for Care Improvement (BPCI) Advanced program, which will go into effect on Jan. 1, 2021, have been released by the Center for Medicare and Medicaid Innovation (CMMI). Based on the payment reconciliation for Years 1 and 2 of the model, CMMI anticipates providing participants with $567 million in reconciliation payments, although there will be significant net losses to the Medicare program. Over the course of the model’s performance periods, CMMI estimates a loss of $2 billion if no changes are made to the program.

CMMI states these updates will make the program “less susceptible to unpredictable changes in policy, coding, and clinical practice for future Model Years.” Notably, individual clinical episodes will be replaced by Clinical Episode Service Line Groups (CESLGs). For cardiology, there are two CESLGs – Cardiac Care (AMI, Arrythmia, CHF) and Cardiac Procedures (Defibrillator IP/OP, Cardiac Valve, CABG, Endovascular Cardiac Valve Replacement, Pacemaker, PCI IP/OP). A participant can no longer opt into just one of the clinical episodes under a CESLG. Each episode under the CESLG will be triggered when the participant reaches the minimum threshold needed for performance.

Deputy Administrator and Director of CMMI Brad Smith states that without achieving the goals of maintaining or increasing quality while reducing costs, CMMI is statutorily obligated to modify or terminate models that do not meet these goals. The agency has decided to modify the current BPCI Advanced model and indicates that CMMI remains committed to testing episode-based payment models. In communication to BPCI Advanced participants, Smith states that “as a next step, we plan to accelerate our work on a new bundled payment model that we anticipate launching as a mandatory model at the completion of BPCI Advanced.”

The ACC continues to engage CMMI and commercial payers on how to best design the next iteration of bundled payment models to support the delivery of high-quality cardiovascular care. This includes exploring ways to improve model aspects such as attribution and quality scoring. The College also continues work toward convening the next Value-Based Care in Cardiology Forum at the end of this year for payers and clinicians to discuss best approaches for designing condition-based cardiac episodes.

Detailed information on the updates to Model Year 4 of the BPCI Advanced can be found on the CMMI website.

Clinical Topics: Cardiovascular Care Team

Keywords: ACC Advocacy, Medicare, Medicaid

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