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The Center for Medicare & Medicaid Innovation (CMMI) wants 100% of providers in upside/downside by 2025 and is using the Bundled Payments for Care Improvement Advanced (BPCI Advanced) model, primary care models, and (increasingly) more mandatory models to get there.
This pressure from the government will put quality directors in a position to highlight their work and play an important role in the organization’s future financial success, says Dave Terry, CEO and co-founder of Archway Health, a company in Watertown, MA, that helps hospitals with bundled payments.
“[CMMI] said last winter that their goal is to move 100% of Medicare providers into some type of meaningful up and downside risk arrangement, which is a pretty big deal. Previously, under the Obama administration, they were looking for value-based contracts, but those could be upside or downside. A lot of providers chose just upside only,” Terry explains. “The current team is focused on moving providers to real risk arrangements because you only see improvements in performance, quality, and costs when there is a downside component to the contracts.”
BPCI Advanced is a model that covers services within a 90-day clinical episode, with a clinical episode defined as beginning with an inpatient admission for an inpatient procedure or the start of the outpatient procedure. Such an episode continues for 90 days after discharge or the procedure. Good performance on quality measures and costs results in more revenue — the upside — but money can be lost if goals are not met — the downside.
BPCI Advanced qualifies as an Advanced Alternative Payment Model under the Quality Payment Program created by the Medicare Access and CHIP Reauthorization Act. Healthcare providers can choose to participate in up to 29 inpatient clinical episodes and three outpatient clinical episodes.1
All alternative payment models include a quality improvement component. Quality professionals will become increasingly important as their organizations explore the options and move forward, Terry says. No matter what model is used, quality metrics will be crucial to seeking the upside rewards of the model. “If the provider organization isn’t able to demonstrate with real data that they are improving on quality, the reimbursement will be impacted,” Terry says. “I think that’s a pretty big deal for quality professionals.”
Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Jonathan Springston, Editorial Group Manager Leslie Coplin, Accreditations Manager Amy Johnson, MSN, RN, CPN, and Nurse Planner Maureen Archambault report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Arnold Mackles, MD, MBA, LHRM, discloses that he is an author and advisory board member for The Sullivan Group and that he is owner, stockholder, presenter, author, and consultant for Innovative Healthcare Compliance Group.