Participation in Model Year 7 launched on Jan. 1, 2024, with the first few months being a critical time for providers. New Bundled Payments for Care Improvement Advanced Model (BPCIA) participants got their footing, and continuing participants were able to change their clinical episode service line groups for the first time since 2020.  If you’re a provider participating in this model, read on for a BPCIA refresher and four fast facts for starting MY7 right. We’ll also cover core analytics activities to support your clinical and operational success.   4 Fast facts on BPCIA Model Year 7  1.   Focus on clinical episodes and episode volume  Before MY7 began, providers used historic baseline data provided by CMS to evaluate which CESLGs they would go at risk for, ensuring there would be sufficient episode volume. Large episode volume (100 episodes/year or more) reduces random variation and helps protect providers from financial risk associated with outlier...

CMS recently made several major announcements about the Bundled Payments for Care Improvement Advanced Model.  The model, which was due to expire at the end of 2023 (Model Year 6), will be extended for an additional two years through Dec. 31, 2025.  New applications will be accepted in 2023 for the two-year extension. Participants still active in Model Year 6 can continue without reapplying by signing an amended and restated participation agreement for Model Year 7.  New methodological changes will be implemented for Model Year 6, which starts on Jan. 1, 2023. Methodological changes include that: the CMS Discount Factor for medical clinical episodes will be reduced from 3% to 2%;  the Peer Group Trend Factor Adjustment cap for all clinical episodes will be reduced from 10% to 5%; the Major Joint Replacement of the Upper Extremity clinical episode category will become a multi-setting episode category by allowing episodes to be triggered when the procedure is performed...

In this edition of DataGen Insights, we look at how alternative payment model participants can ensure their processes and workflows are optimally set up for success. To help, DataGen listed the top three strategies all providers participating in APMs can employ and created a handy checklist to enable maximum returns and reduce financial risk. Please explore our website to learn more about our  products and services .  Download DataGen Insights today .  We hope you enjoy!

The Primary Care First Model , an alternative payment model offering an innovative payment structure for the delivery of advanced primary care, welcomed the involvement of Cohort 2 participants on Jan. 1 . This cohort, which was open to all primary care practices that met the eligibility criteria, will participate from 2022 to 2026. Participants in PCF Cohorts 1 and 2 can expect the following benefits: an opportunity to increase revenue with performance-based payments that reward participants for reducing acute hospital utilization; the ability to assess and improve performance through actionable, timely data; less administrative burden so providers can spend more time focusing on patient needs; and potential to become a Qualifying APM Participant , which includes eligibility for a 5% incentive payment and eliminates Merit-based Incentive Payment System reporting requirements. To ensure that new and prior participants succeed in this model, DataGen has compiled and answered some of t...

Alternative payment programs are critical to payment and care delivery transformation. CMS is introducing new alternative payment models that provide opportunities to deliver better value of care and support healthcare innovation in the years to come. Rising healthcare trends should be taken into consideration when evaluating new APMs. Yet, keeping ahead of which programs offer you the greatest opportunity can be a major challenge. DataGen put together Navigating Alternative Payment Models: A User's Guide , offering insights on the participation categories—and detail on programs within each category—this resource can help you determine the best course for your organization’s future. Download our user's guide to learn about new APMs, implications for providers and data-driven strategies for successful pro gram execution.

As we emerge from a global pandemic, accountable care organizations must address key new trends now to maintain progress toward value-based care and mitigate financial risk.  Analytics are key to helping ACOs gain a better understanding of trends so they can identify opportunities to drive quality improvement. These trends include: gaps in access to clinical care;  shifts in patient volume; increased demand for virtual care; and  social determinants of health challenges.  To better understand rising trends and actions providers should take, we will reach out to hospital and health system leaders to discuss how recent trends influenced their decision to adopt value-based contracts. Then, during our July 28 webinar, we will release a comprehensive market report on these trends and implications for the future. Preventing gaps in access to clinical care Advanced payment models incentivize ACOs to deliver high-quality care and close gaps in care for patients, thereby earn...

On April 29, CMS issued a final rule to extend the Comprehensive Care for Joint Replacement model by an additional three performance years. A number of modifications effective in the extension period aim to improve the model and reflect Medicare policy changes over the last several years. CMS anticipates that CJR will save the Medicare program an additional $217 million over the extension period. The following summarizes the most notable model changes: Three new performance years have been added: PY 6 will include episodes that end between Oct. 1, 2021 and Dec. 31, 2022; PY 7 will include episodes that end between Jan. 1, 2023 and Dec. 31, 2023; and PY 8 will include episodes that end between Jan. 1, 2024 and Dec. 31, 2024. Episode definitions under the model have been expanded to include total hip arthroplasty and total knee arthroplasty procedures performed in the hospital outpatient setting. The episode categories under the extension are site-neutral and are defined as: MS-DRG 470: ...

What can you do while CMS decides how to handle the mandatory program? As the healthcare community continues its march away from fee-for-service models, bundled payment initiatives have risen in popularity—thanks in no small part to their ability to fuel cost savings and significantly improve care outcomes. The Centers for Medicare and Medicaid Services (CMS) issued an interim final rule in March that delays implementation of the new bundled payment model for heart attack and cardiac bypass surgery services; expansion of the existing Comprehensive Care for Joint Replacement bundling model; and implementation of a new cardiac rehabilitation incentive payment model, from July 1 to October 1, 2017. Prior to the interim rule, CMS’ push forward on bundled payments focused the industry on episodic efficiency. The delay has pushed these initiatives back three months and, as DataGen’s Vice President, Kelly Price recently explained, is causing confusion and worry among participants.

The challenges and benefits of bundled payments and risk-based arrangements is one of the biggest issues facing the healthcare field. Kelly Price, DataGen’s Vice President and Chief of Healthcare Data Analytics, and Stephanie Kovalick, Chief Strategy Officer at Sage Growth Partners sat down to help shed some light on ways to succeed with bundled payments and risk-based payment models. Read more about this conversation in our new installment, “The Future of Payment Reform: How can providers, patients, and payers benefit—and who bears the burden? ” 

As we look ahead to 2017—a year that’s sure to bring changes to the way healthcare is delivered under the new Trump Administration—Kelly Price, DataGen’s Vice President and Chief of Healthcare Data Analytics, sat down with Stephanie Kovalick, Chief Strategy Officer at Sage Growth Partners, to provide expert perspective on the current and future states of payment reform. Download