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*In The Know with BPCI Advanced*






*September 12, 2024*




*Issue No. 52*






*Understanding the BPCI Advanced 90-Day Episode*
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The BPCI Advanced model emphasizes care redesign and coordination during a 90-day episode, with the goal of both improving patient outcomes and quality of care, as well as reducing unnecessary utilization where feasible. However, one misconception about the best ways to achieve these goals is that providers may do so by avoiding or postponing routine and/or preventative care during the 90-day clinical episode. CMS considers such practices to be care stinting, which is prohibited behavior, per the requirements in the BPCI Advanced Participation Agreement. Care stinting, or avoiding necessary care, can jeopardize a beneficiary’s long-term health. Fortunately for BPCI Advanced participants, preventative and routine care is built into the baseline pricing methodology of a BPCI Advanced episode.

 

*The Baseline in BPCI Advanced - What Does It Include? *

Under BPCI Advanced, CMS calculates target prices using claims data during a historical baseline period, which includes routine and preventative care and other spending. Routine care such as follow-up visits and lab tests, along with preventative services like vaccinations and screenings, are accounted for within the historical data. CMS also incorporates many additional factors in setting target prices, including patient case mix, comorbidities, and prior hospitalizations. As a result, the target price is intended to reflect average spending during an episode, which includes both care that occurred during the acute hospitalization (or outpatient episode) as well as regular care that occurs in the following 90 days.

 

*Reasons to Provide Routine and Preventative Care:*

_Prevention of Complications_ - Regular monitoring and management of chronic conditions can help prevent complications that might otherwise result in hospital readmissions or other costly interventions. For instance, consistent management of diabetes or hypertension during the 90-day episode can prevent exacerbations that would require acute care.

_Improved Patient Outcomes _- Preventative care plays a significant role in achieving better health outcomes by identifying and addressing potential health issues before they become serious. Since reconciliation amounts are adjusted for quality performance, improving patient outcomes can also benefit participants’ financial performance in the model.

_Spending and Utilization_ - Providing routine care can help control spending within the episode. By preventing the escalation of health issues, providers can avoid the higher spending associated with emergency care or rehospitalization. This aligns with the financial incentives of the model, which rewards providers who achieve targets on quality and spending.

Ultimately, the BPCI Advanced model is about improving patient health through coordination of appropriate care. Any reduction or withholding of care to minimize spending during the episode is not permitted under the model. CMS has safeguards in place, such as monitoring and audit activities, to detect incidents of care stinting.






*BPCI Advanced Website*

Main Page [ https://innovation.cms.gov/innovation-models/bpci-advanced ]| Participant Resources [ https://innovation.cms.gov/innovation-models/bpci-advanced/participant-resources ] | Quality Measures [ https://innovation.cms.gov/innovation-models/bpci-advanced/quality-measures ]

If you have questions about BPCI Advanced, reach out to the Model Team Helpdesk at *BPCIAdvanced@cms.hhs.gov* <BPCIAdvanced@cms.hhs.gov>.

Please do not respond directly to this message as the CMS Listserv inbox is not monitored.

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