A little over a month after the program was announced, the American Hospital Association is voicing concerns over a lack of "sufficient operational detail" from the Centers for Medicare and Medicaid Services on the Bundled Payments for Care Improvement Advanced model and urging the agency to delay its implementation.
In an eight-page letter to the agency's administrator Seema Verma, the AHA's Executive Vice president Thomas Nickels has asked CMS to provide a "complete package of programmatic information" and push the application deadline back by roughly a month, from March 12 to April 16.
First, under the program's current specs, CMS will calculate Medicare fee-for-service expenditures for a clinical episode against a target price, basing that on the historical Medicare FFS expenditures for that clinical episode. The target prices will be adjusted using risk adjustment models that consider hospitals' past performance, patient and peer group characteristics.
Currently CMS plans to publish the target prices only for the first two model years. The AHA is urging them to publish the target prices for subsequent years in a "timely manner." AHA also wants CMS to take into consideration either a national or regional historical episode payment, depending on which is higher. The plan to adjust targets on a semi-annual basis is not sitting well with the AHA either.
"A number of hospitals participating in the BPCI and Pioneer accountable care organization models have indicated that the target prices for these programs have often changed during the performance period, sometimes significantly and inexplicably. To further stabilize the target prices for BPCI Advanced participants, we urge CMS to update its underlying assumptions related to the target price annually, rather than semi-annually," the letter said.
The program qualifies as an advanced payment model under MACRA. The AHA would like to see the BPCI distinguish between Medicare and non-Medicare enrolled conveners, and to allow participation without downside risk. They also want to see it qualify not just as an APM, but also as a MIPS APM, and expressed disappointment that this is not currently the case.
They also want to see flexibility when it comes to sites of care. "The waiver of certain Medicare program regulations is essential so that hospitals and health systems may coordinate care and ensure that it is provided in the right place at the right time. BPCI Advanced participants should have maximum flexibility to identify and place beneficiaries in the clinical setting that best serves their short- and long-term recovery goals."
Timely notice of excluded services from each bundled care episode is of concern to the AHA, as is a lack of information on the program's composite quality score adjustment. Payment under the BPCI Advanced model will hinge on a participants' performance on certain quality measures, using a pay-for-performance methodology. CMS will calculate a score for each measure at the clinical episode level, then scale the scores across all clinical episodes "attributed to a given episode initiator." the scores will be weighted based on clinical episode volume and totaled to come up with a Composite Quality Score.
At reconciliation, CMS will adjust the positive or negative total reconciliation amount by the episode initiator-specific CQS. For the first two years of the model, that adjustment can not exceed 10 percent. The AHA wants more details on how quality measure benchmarks translate to the CQS so that applicants can assess the impact of the CQS adjustment. The AHA also is also demanding clarification on which of the quality measures would be applied to which clinical episodes, and expressed concern over the measure themselves, calling them poorly aligned with the care episodes and patient populations in the model.
Finally, the AHA wants to see sociodemographic adjustment to the readmission, complication and mortality measures. Nickels argued that community factors like a patient's ability to afford their medicine and access to healthy foods, can influence whether a patient's health improves after a discharge or not. AHA proposed using the same approach as the hospital readmissions penalty program, wherein hospitals are put in peer groups based on the number of dual-eligible patients they treat.
Failure to make such an adjustment, AHA argued, could ultimately harm patients and exacerbate healthcare disparities, as well as potentially mislead patients, policymakers and payers by masking the community factors that affect health outcomes.
"The changes we recommend above would help facilitate hospitals' participation in and success under the BPCI Advanced model with regard to providing quality care to Medicare beneficiaries and achieving savings for the Medicare program," the letter said.