In our ongoing effort to be the preferred value based care and bundled payment partner for acute care hospitals (ACHs) and physician group providers (PGPs), Fusion5 is sharing the following information provided by the Center for Medicare and Medicaid Services (CMS) regarding new bundles and other changes providers can expect to see in BPCI-A Model Year 3, beginning January 1, 2020.
Outpatient Total Knee Arthroplasty (TKA) Pricing
In response to TKA procedures being removed from Medicare’s Inpatient-Only List (IPO), outpatient TKA has been added as part of the multi-setting Major joint replacement of the lower extremity (MJRLE) Clinical Episode, in addition to inpatient TKA. Since TKA was removed from the IPO List in the beginning of 2018, resulting in relatively fewer outpatient TKAs in the Model Year 3 baseline period, the standard procedure for constructing Target Prices was modified slightly to better reflect the setting mix expected in the Performance Period. Specifically, inpatient TKA Clinical Episodes without Major Complication or Comorbidities (MCC) from 2017 and earlier are selected for conversion to “pseudo-outpatient-TKA” Clinical Episodes, which means their observed Clinical Episode spending is edited to mimic that of an outpatient TKA Clinical Episode during the Performance Period.
For additional information on how MJRLE Benchmark Prices were constructed, please see the Appendix in the Target Price Specifications Model Year 3 document.
Percutaneous Coronary Intervention (PCI) followed by Transcatheter Aortic Valve Replacement (TAVR)
Participants have indicated an increasing prevalence of PCI Clinical Episodes containing a TAVR procedure in the 90-day post-anchor period. The inclusion of TAVR costs in the PCI Clinical Episode is impacting a Participant’s ability to control Clinical Episode expenditures. To mitigate this concern, we will be modifying the precedence rules for this overlapping scenario. Therefore, if a PCI Clinical Episode overlaps with a TAVR Clinical Episode, where the PCI start date is on or before the TAVR start date, the TAVR Clinical Episode will be retained and the PCI Clinical Episode will be canceled, regardless of the participation status of the Episode Initiator (EI) associated with these Clinical Episodes.
Additionally, the cost of TAVR inpatient stays will be carved out of PCI Clinical Episodes to prevent artificially high PCI Target Prices.
Spinal Fusion Clinical Episodes
BPCI Advanced was planning to include three spinal fusion Clinical Episode categories: Cervical, Non-cervical, and Combined anterior posterior (henceforth abbreviated to “Combined”). At the beginning of fiscal year 2018, the logic used to assign MS-DRGs was updated so that some hospital stays that would have been classified as Cervical or Non-cervical spinal fusions prior to the change were classified as Combined spinal fusions after the change; and similarly the reverse scenario occurred. This had significant implications for hospitals’ volume and thus their eligibility to participate in the three spinal fusion Clinical Episodes, including a Physician Group Practice’s (PGP) ability to initiate one of the spinal fusion Clinical Episodes at those affected hospitals.
To alleviate this problem, CMMI has decided to pool the three spinal fusion Clinical Episodes into a single “Spinal fusion” Clinical Episode. Analysis of preliminary MY3 Clinical Episodes demonstrates that using the pooled Spinal fusion Clinical Episode, rather than keeping separate spinal fusion Clinical Episodes, will significantly increase the number of hospitals eligible to initiate Clinical Episodes with Cervical spinal fusion, Non-cervical spinal fusion, and Combined spinal fusion triggers. Under the new pooled Clinical Episode category, the three types of spinal fusion Clinical Episodes will be risk adjusted in a single shared model and will share a single Target Price, which will update based on realized proportions of Clinical Episodes from MS-DRGs in each of the three aforementioned categories.
For additional information, please review the Pooled Spinal Fusion Clinical Episode Target Price Description document. An updated Clinical Episode Definitions can also be found by clicking here.
Part B Drug Exclusions
In Model Years 1&2, expenses from Part B drugs on the CMS Average Sales Price (ASP) list are excluded from Clinical Episode expenditures. In an effort to move more towards total cost-of-care, Part B ASP drugs will be included in Clinical Episodes’ costs and thus reflected in Target Prices for Model Year 3. However, to curb avoidance of beneficiaries requiring high cost drugs and account for clinically unrelated drugs, a limited list of Part B drugs will be excluded. Part B drugs are identified for exclusion for either being high cost (mean costs greater than $25,000) or low volume (billed in less than 41 Clinical Episodes), or clotting factors for hemophilia patients.
In addition to the above exclusions, further Part B drug exclusions will be applied to the Inflammatory Bowel Disease (IBD) Clinical Episode. Treatment for IBD may include drug therapy, and depending on the biologic used, can fall under either Medicare Part B or Part D coverage. The current structure of BPCI Advanced does not include Part D drug costs in Clinical Episodes or Target Prices, making it difficult to account for and control Part D spending. To ensure that BPCI Advanced does not induce perverse shifts in prescribing practices, a list of IBD related Part B drugs will be excluded. We are taking into consideration the inclusion of Part D drugs in future Model Years.
Please review the BPCI Advanced Exclusions Lists identified by MS-DRGs and HCPCS.
CMS recognizes the importance of Cardiac Rehabilitation services to improve long-term cardiovascular outcomes for beneficiaries. Cardiac Rehabilitation services are traditionally underutilized and providers may be disincentivized from recommending therapy in the Performance Period if there was limited uptake during the baseline period. To remove disincentives and encourage providers to prescribe Cardiac Rehabilitation services to beneficiaries, CMS will carve Cardiac Rehabilitation/Intensive Cardiac Rehabilitation spending out of Clinical Episode spending in both the baseline and Performance Periods.
The benefits of removing Cardiac Rehabilitation costs from all Clinical Episodes can be two-fold; the potential to improve beneficiary wellbeing and reduce spending via decreased readmissions in the long-term. Major Teaching Hospital To improve the transparency of the method used to classify hospitals as training and research centers for the purposes of risk-adjustment, CMS will replace the Academic Medical Center (AMC) variable with a flag that takes a value of one if and only if a hospital’s intern and resident to bed ratio is at least 25%, starting in Model Year 3. Hospitals that meet this criterion are called Major Teaching Hospitals (MTHs).
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