What are the financial risks in TEAM?  Hospitals are preparing for the launch of the Centers for Medicare and Medicaid Services’ (CMS) Transforming Episode Accountability Model (TEAM) in 2026.   To help you understand both the opportunities and financial risks for participants, DataGen put together a comprehensive white paper, CMS Transforming Episodes Accountability Model Financial Risk Guide.   [Access it Now for Key Updates]  Keep reading for highlights of what’s inside.   Exploring the goals and structure of CMS TEAM Model  CMS TEAM Model is designed to enhance care quality and cost-efficiency. It aims to revolutionize how hospitals manage patient care over 30-day episodes for specific surgical procedures by holding them accountable for the quality and cost of care delivered.   As seen on CMS’ Transforming Episode Accountability Model overview fact sheet , this model not only seeks to improve patient outcomes, but encourages hos...

CMS released important updates for Model Year 7 of Bundled Payments for Care Improvement Advanced. Providers who applied and have been accepted into the third cohort will soon begin the baseline evaluation and episode selection process. In this blog, we’ll cover important upcoming BPCIA dates and what you need to know now and for the future. Important upcoming CMS BPCIA dates Here are important BPCIA dates you’ll want on your radar in the coming months: September 2023 : At the beginning of the month, CMS will upload preliminary BPCIA Model Year 7 episode target prices and baseline episode and claims data on the CMS Enterprise Portal. As a provider, you will need to use these data to evaluate which clinical episode service line groups you want to participate in during the new model year. Dec. 4, 2023 : Providers who choose to move forward in the model have until this date to submit their MY7 Participation Agreement and Participant Profile, which will indicate selected episode initiators...

CMS’ Bundled Payments for Care Improvement Advanced program will soon kick off a two-year program extension through 2025. Model Year 7 (Jan. 1 - Dec. 31, 2024) will be the first time that current participants (acute care hospitals and physician groups) can update their episode of care selections since 2020. MY7 is also only the second time since BPCIA launched (2018) that CMS will allow new providers to join. Applications were due May 31, 2023. Whether you’re a new applicant or a current participant looking to update your episode selections to improve results, it’s never too early to prepare. BPCIA participants take on immediate full risk. This makes it critical to choose episodes that present the greatest savings, incentive and quality improvement opportunities. Episode selection — An art and a science For optimal BPCIA episode selection, providers must analyze their performance from the historic baseline period and design their clinical effectiveness strategies accordingly. It’s impo...

As healthcare professionals continue to navigate the COVID-19 pandemic, it's important to understand how it has impacted healthcare trends. “Trends in Sepsis and Pneumonia During COVID-19: Lessons From BPCIA,” a recent research article published in The American Journal of Managed Care, explores how COVID-19 has impacted sepsis and pneumonia care and costs. Coauthored by Alyssa Dahl, DataGen’s senior director of advanced analytics, and John Kalamaras, DataGen’s director of business intelligence analytics, along with experts from the Association of American Medical Colleges, the article explores the changes in cost and utilization for sepsis and pneumonia in non-COVID-19 episodes before and during the pandemic, and during the pandemic for patients with and without COVID-19. The analysis used claims data from eight teaching hospitals participating in sepsis and pneumonia episodes in the Bundled Payments for Care Improvement Advanced model. BPCIA is a Medicare value-based care bundle...

The Bundled Payment for Care Improvement (BPCI) Advanced Model is now open for applications until May 31, 2023. This model provides a unique opportunity to acute care hospitals and physician group practices who are looking to: evaluate their bundle performance; rejoin if they have previously dropped out due to being under a convener; or take advantage of the changes to the model. With a small window to sign the participation agreement, you’ll need experts to process data quickly and accurately for evaluation. BPCI Advanced Program Details The Centers for Medicare & Medicaid Services (CMS) announced in October 2022 that this program will extend from January 2024 to December 2025. Data used for evaluation will be taken from the baseline period between October 2018 and September 2022. A participation agreement will be sent out in September 2023 and needs to be signed by October 2023 in order to participate. Those who apply before the May 31 deadline will benefit ...

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...

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: ...

It’s been a year: a year since the first lockdowns and a year since the landscape of healthcare in the U.S. changed forever. While we’re still evaluating the impacts of the pandemic on healthcare policy, we now have seen enough data to assess the effect of the past year on alternative payments models and how participants are reacting. It’s been reassuring to see the strength of APMs has broadly held steady, as has the resolve of the participants in those programs, despite the impact of the COVID-19 pandemic. Here’s what we’ve learned this year, along with what (we think) those lessons can teach us about the future. COVID-19 has not stopped the progress of APMs — but it is delaying it. COVID-19 has extended the period of some programs, like the Comprehensive Care for Joint Replacement and Oncology Care Model, and delayed the start of others, like Kidney Care First and the Radiation Oncology Model. This is, in part, a function of an overwhelmed system. As policymakers and healthcare org...

The COVID-19 pandemic has impacted every aspect of our healthcare system. That’s true for participants in the Oncology Care Model and Bundled Payments for Care Improvement Advanced programs. Organizations in these programs had to make important decisions regarding the overlap of their program performance periods with the COVID-19 public health emergency. Several trends have begun to emerge from these choices. Here’s what DataGen’s analysts have seen from the data: BPCIA For performance periods that overlapped with the PHE, BPCIA participants had to decide if they would remove all upside and downside risk, or just remove COVID-19 patients from their reconciliation. From our analysis, it appears that decisions were balanced between these two options. We are not aware of any episode initiators who chose to continue their reconciliations as usual with no exclusions at all. Here’s what we believe drove those decisions: Opting out of the performance period reconciliation entirely by removing...

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 

The healthcare industry is in a state of quiet anticipation as we await the second data feed from the Centers for Medicare and Medicaid Services’ (CMS) Comprehensive Care for Joint Replacement (CJR) bundled payment model. Participants still have a lot of questions?  Will the program help hospitals deliver better accountability for care? Will care be coordinated more effectively? Is it going to help reduce costs—and if it does, for whom?  Learn more

Launched on April 1, 2016, CJR is the first mandatory bundled payment program from CMS.  Affecting more than 750 hospitals in 67 markets, CJR creates a host of new challenges and opportunities for participants. Read the article to learn more about the program and prepare for the initial data release .

Announced by the CMS in January 2015, OCM is one of the most recent programs in a litany of new experiments.   Simplifying and organizing the complex data and policy component of this program requires specialized expertise in healthcare analytics. Read about DataGen's recent work related to the OCM in Achieving Data-Driven Success Under the OCM , which identifies four critical areas data analytics will need to address for any bundled payment model. Download the article .

It is critical that healthcare executives understand and stay abreast of the implications on their organizations of the rapidly evolving innovation in healthcare payment and delivery driven by Medicare and other payers. This white paper examines areas of opportunity and ways for hospitals to achieve CJR success. Download Now

The Post-Acute Care Perspective on Bundled Payments--Webinar View Now

CMS has released its final rule for the Comprehensive Care for Joint Replacement (CJR) model.  In addition to dropping one “C” from the acronym, there are several substantive changes from the proposed rule; most important of which is that the program will now begin on April 1, 2016.   DataGen is revising its analytics to reflect all of the changes.  We will be ready to share insights on opportunities under CJR prior to the program’s official start.  We have updated our "Ten Things" paper to reflect the final rule.   Download White Paper

Hospitals may be the only risk-bearing entities under the Centers for Medicare and Medicaid Services' (CMS) Comprehensive Care for Joint Replacement (CJR) payment model, but there are major implications for post-acute care (PAC) providers.  Based on our review of the CJR program, this white paper outlines the top seven things PAC providers need to know about and act on to be successful partners in this and other emerging payment models. Download White Paper

In July 2015, the Centers for Medicare and Medicaid Services (CMS) proposed its Comprehensive Care for Joint Replacement (CCJR) payment model, a pilot bundled payment program for the most common inpatient surgeries for Medicare beneficiaries—hip and knee replacements, known as lower extremity joint replacements (LEJRs). While CMS’ increasing interest in bundled payments has been apparent, the announcement of this mandatory initiative was a surprise to many, given that the Bundled Payments for Care Improvement (BPCI) demonstration program, initiated in 2013, is still in its early stages.  CCJR would be mandatory for hospitals in 75 Metropolitan Statistical Areas (MSAs). This white paper examines the top ten things every hospital executive should know about the proposed CCJR program, its relationship to the BPCI demonstration, and the implications of this model for other innovative payment models.  Download White Paper