Full Episode Be Careful With My Heart

[Giulia Satmary]

TheBundled Payments for Care Improvement Advanced (BPCI Advanced) Model is part of the continuing efforts by the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (Innovation Center) 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.

The first cohort of Participants started participating in the Model on October 1, 2018. The second cohort started on January 1, 2020. The third cohort of Participants will start on January 1, 2024, and may participate until the BPCI Advanced Model period of performance ends on December 31, 2025.

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.

For purposes of BPCI Advanced, a Participant is defined as an entity that enters into a Participation Agreement with CMS to participate in the Model. BPCI Advanced will require downside financial risk of all Participants from the outset of the Model Performance Period. There are two categories of Participants: Convener Participants and Non-Convener Participants.

A Non-Convener Participant is the Episode Initiator (EI) that bears financial risk only for itself and does not have any Downstream EIs. Only PGPs and ACHs may participate in BPCI Advanced as a Non-Convener Participant.

An EI is a Medicare-enrolled provider or supplier that can trigger a Clinical Episode under BPCI Advanced. In this Model, EIs can only be PGPs or ACHs, including ACHs where outpatient procedures are performed in hospital outpatient departments (HOPDs).

Physicians are ideally positioned to direct high-value, patient-centered care, and they are crucial to the success of BPCI Advanced. The model emphasizes specialty physician engagement and provides resources to facilitate peer-to-peer learning.

A BPCI Advanced Clinical Episode is structured to begin either at the start of an inpatient admission (the Anchor Stay) to an Acute Care Hospital (ACH) or at the start of an outpatient procedure (the Anchor Procedure) in a Hospital Outpatient Department (HODP). Inpatient admissions that qualify as an Anchor Stay will be identified by Medicare Severity-Diagnosis Related Group (MS-DRGs) codes, while outpatient procedures that qualify as an Anchor Procedure will be identified by Healthcare Common Procedure Coding System (HCPCS) codes. The Clinical Episode length will be the Anchor Stay plus 90 days beginning the day of discharge or the Anchor Procedure plus 90 days beginning on the day of completion of the outpatient procedure. Clinical Episodes are constructed to include all items and services that are provided during the Clinical Episode window, with some exclusions.

Starting 2023 the BPCI Advanced Model expanded the multi-setting Clinical Episodes Category of the Major Joint Replacement of the Upper Extremity to include outpatient Total Shoulder Arthroplasty procedure when triggered by HCPCS 23472. Therefore, since the start of Model Year 6, and continuing through Model Years 7 and 8, the model has 8 Clinical Episode Service Line Groups with 29 Inpatient, 3 Outpatient, and 2 multi-setting Clinical Episode Categories.

The CMS Innovation Center provides Participants the flexibility to report quality measure performance through either an Administrative Quality Measures Set or through a clinically aligned, actionable Alternate Quality Measures Set. Up to five quality measures will apply to each Clinical Episode. To view the list of available Fact Sheets specific to each quality measure for Model Years 1-7, please visit the BPCI Advanced Quality Measures webpage.

The BPCI Advanced Model uses a retrospective bundled payment approach. Specifically, under BPCI Advanced, CMS may make additional payments to Model Participants or Model Participants may owe a payment to CMS after CMS reconciles all non-excluded Medicare FFS expenditures for a Clinical Episode against a Target Price for that Clinical Episode. The Target Price calculations, Reconciliation calculations, and attribution of Clinical Episodes to Participants will each occur at the Episode Initiator (EI) level.

CMS has developed a large number of technical resources providing guidance on Clinical Episode Exclusions, Clinical Episodes Construction, Reconciliation and Target Prices specifications for each model year. Please visit the Participants Resources web page to access these documents.

Baptist Health Heart & Vascular Care offers patients access to new technologies years before other regional hospitals. Our team of multidisciplinary physicians represents the complete spectrum of cardiovascular care and is dedicated to providing you and your family with the best treatment.

We provide convenient cardiovascular care throughout Miami-Dade, Broward, Palm Beach and Monroe Counties across our 11 hospitals, specialty physician practices and renowned centers of excellence: Baptist Health Miami Cardiac & Vascular Institute and Christine E. Lynn Heart & Vascular Institute.

Our researchers play a vital role in helping us better understand heart and vascular disease. They participate in a wide variety of clinical trials dedicated to improving treatments that will ultimately lead to better patient outcomes. Learn more about their work and what it means to be involved in a clinical trial.

Hospital readmission is just one of many quality targets that cardiologists and Horizon BCBSNJ have agreed to evaluate as part of the heart failure EOC. The number of emergency room visits and adherence to clinical guidelines, for example, also play a part in determining whether participating doctors have reached the quality goals for each cardiac episode.

An episode can be triggered by several factors, including the initial diagnosis or a visit to an acute care facility, said Gips. Episodes factor in health care claims associated with a heart condition 30 days before the triggering event and 90 days following. The EOC program bundles all related claims and then compares the total cost of the episode against the benchmark historical cost. In 2019, Horizon BCBSNJ reported more than 1,600 heart failure episodes.

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Background: Although intensively studied in hospital and emergency settings, chest pain has remained largely unstudied in primary care, where it is associated with considerable diagnostic uncertainty and high utilization of medical resources.

Methods: We employed an established primary care research network to prospectively collect detailed information on episodes of care for chest pain. Over a 12-month period, Michigan Research Network (MIRNET) clinicians prospectively collected demographic, clinical, and clinician decision-making information for all patients seen in their offices with the complaint of chest pain.

Results: Three hundred ninety-nine complete episodes were collected and used for analysis. Episodes were well distributed among urban, rural, academic, and private sites. The average episode length was 1.53 visits. Musculoskeletal chest pain accounted for 20.4% of all diagnoses, followed by reflux esophagitis (13.4%) and costochondritis (13.1%). Stable angina pectoris was the primary diagnosis in only 10.3% of episodes, unstable angina or possible myocardial infarction in 1.5%. Most of the ancillary services used were directed toward finding or excluding cardiac disease.

Conclusion: A practice-based network can be used to study episodes of care. Resource use during episodes of chest pain in primary care are directed toward exclusion of cardiac disease, despite the surprisingly low frequency of cardiac diagnoses.

The eligible providers for ECIP certification include general or specialist physicians, clinical nurse specialists, nurse practitioners, physician assistants, physical therapists, skilled nursing facilities, home health agencies, long-term care hospitals, hospices, and inpatient rehabilitation facilities. ECIP emphasizes post-acute care coordination and outcome improvements after discharge, involving not only physicians and advanced practice nurses but also engaging post-acute care facilities like physical therapists.

ECIP offers hospitals a choice of participating in 23 clinical episode categories. In CY 2023, hospitals selected approximately 5.8 clinical episode categories on average. The most commonly selected clinical episode categories are:

ECIP requires hospitals to share earned incentive payments with their care partners or provide a significant amount of care management resources or other intervention resources to their care partners.

The ECIP Track Implementation Protocol (ECIP 2024 Track Template) outlines the parameters of the program. Hospitals have a high degree of flexibility to design their initiatives within those parameters.

Thirty-day Episodes of Care Payments are Medicare fee-for-service reimbursements that have been standardized to remove factors unrelated to clinical care, such as differences in geographic location and support for medical student education. Thus, payments are a dollar-value reflection of the care choices hospitals make for their patients. While not a measure of quality, variation in payments within and between the index and post-acute care settings may be influenced by a hospital's unique practice patterns. Understanding which care settings are accounting for the greatest proportions of payments and which are driving differences in payments can inform efforts to reduce spending and improve efficiencies in care.To begin exploring the data:

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