Health Care Matters | June 7, 2024
BPCI Advanced Model Evaluation Shows Net Savings to Medicare in 2021
Last week the CMS Innovation Center released its fifth annual evaluation report on the Bundled Payments for Care Improvement (BPCI) Advanced Model, showing net savings of $465 million to Medicare in 2021. Results during year 4 (2021) of BPCI Advanced revealed a $930 per episode reduction, or 3.5% of the baseline mean, in total episode payments relative to the comparison group. The evaluation did not find a consistent relationship between the model and patient experience and functional status in 2021 or 2022.
Why It Matters
This is the first time that BPCI Advanced or its precursor, BPCI, has demonstrated savings to Medicare. Notably, these results come after the Innovation Center made substantial changes to the model design including requiring participants to choose from broader groups of clinical episodes rather than selecting individual episodes and adjusting the target price with a retrospective trend rather than using an exclusively prospective trend. These changes likely contributed to the 37% decline in participation from 2020 to 2021 but even with that decline the total savings generated in 2022 ($465M) outweigh the combined Medicare losses from the first three years of the model ($180M). Not surprisingly, the majority of savings came from reductions in post-acute utilization and spend over the 90-day episode window. Should the proposed Medicare mandatory bundled payment model (TEAM) go forward as planned, it will be interesting to see if the shorter time period (30 days instead of 90) still offers sufficient incentive and opportunity to control unnecessary spending.
2022 Quality Payment Program Performance Report Released
Last month CMS released the 2022 Quality Payment Program (QPP) Participation and Performance Results providing insight into clinicians’ performance in either the Merit-based Incentive Payment System (MIPS) or in an advanced alternative payment model (Advanced APM). These results will affect the Medicare reimbursement clinicians receive for 2024. The results reveal ~624K clinicians will receive a MIPS payment adjustment. The maximum payment adjustment for payments made in 2024 is 8.26%, compared to 2023 when the maximum upward adjustment was just 2.24%. The mean and median final score for MIPS-eligible clinicians were both lower than the 2021 mean and median scores.
Why It Matters
While the 8.26% upward adjustment is much more substantial than we have seen under MIPS in prior years, providers should not count on seeing adjustments that high in future years. A large portion of the 8.26% adjustment comes from the exceptional performance adjustment, which allots additional funding to clinicians and groups that earned a final MIPS score of 89 or better. 2022 was the last performance year for which the exceptional performance bonus applied and going forward, MIPS will be a budget neutral program in which the adjustments from the low performers funds the adjustments to high performers without any special pools of funding available for exceptional performers.
Had the bonus not been in place, the top payment adjustment for 2024 would have been 2.24%, still an increase from the prior year but substantially lower than the 8.26%. See regs and eggs blog for more insights on the QPP results. MIPS is currently under review by Congress including a white paper from the Senate Finance Committee last month, due to feedback from stakeholders that it not driving quality and patient outcomes as intended. With the sunsetting of the Advanced APM bonus and the exceptional performance bonus in MIPS, we expect continued lobbying by stakeholders to Congress to revamp QPP and better align incentives for value-based care participation and improved patient outcomes.
Advancing Health Equity Through Value-Based Care: CMS Innovation Center Update
Elizabeth Fowler, the Innovation Center director at CMS along with others from her team released an article in Health Affairs this week that catalogued the 9 models released in the last year focused on Health Equity and eliminating health disparities. The article notes the Innovation Center focus on safety net providers including FQHCs that were previously excluded from these tests of change. New models also now include health equity plan, data collection and Health Related Social Needs (HRSN) screening requirements and test payment adjustments that account for the additional resources needed to care for underserved populations.
WHY IT MATTERs
The Innovation Center along with the rest of the policy makers across state and federal agencies are still in the beginning stages of testing how to incentive health care organizations to invest to eliminate health disparities. Previous models were unintentionally less friendly to safety net providers due to the resources needed to participate, the required downside risk and eligibility requirements that excluded FQHCs, RHCs and CAHs because of unique Medicare billing characteristics. This last year has signaled a strong pivot toward not only inclusion but a focus on designing models that encourage participation from these providers while in lockstep collecting the data to inform these efforts. Expect to see iterations of these approaches with frequent updates to current models around payment adjustments, data collection and plan requirements. To understand where the Innovation Center is going, take a closer look at the pieces of these health equity approaches they keep, and what they change, update or discard in new model announcements.
WHAT WE ARE READING
Responses to CMS Request for Information on
Medicare Advantage Data
The AHA and the Brookings Institution were some of the many voices that submitted letters to CMS in response to a request for information (RFI) regarding Medicare Advantage data.
What We Are Watching
CMS OMH/CDC OHE Health Care Workforce and
Health Equity Inclusion Virtual Forum
June 12, 2024, 11 am – 12 pm ET
Use This Link To Join:
https://us06web.zoom.us/webinar/register/WN_1K8auFOiSnidQUHtwg8E2g
special announcement
It is Medicare Fraud Prevention Week!
Help your Medicare loved ones identify common scams:
Receiving bills for services or supplies that weren't ordered or were never received.
Getting orders for tests or services that are unnecessary.
Being billed for services that are covered and paid for by Medicare.
For more information on preventing fraud and to find a local Senior Medicare Patrol (SMP) office, visit SMPresource.org.
