Quarter 4 2020


I. BPCI-A Model Year 4 Program Updates

The Centers for Medicare & Medicaid (CMS) has announced several programmatic changes to the Bundled Payments for Care Improvement Advanced (BPCI-A) model. These changes go into effect on January 1, 2021 and will impact Model Year (MY) 4 participation.  The most impactful change to Tower Health (TH) is the introduction of Clinical Episode Service Line Groups.

  • Clinical Episode Service Line Groups (CESLGs)

Beginning MY4, participants will be required to select and be held financially accountable for an entire CESLGs rather than an individual clinical episode. For example, in MY3 Reading selected and was held accountable for sepsis. If Reading wanted to select sepsis for MY4, the hospital would have to select the medical and critical care CESLG and be held financially accountable for all six clinical episodes included within the CESLG. Figure 1 provides a breakdown of which clinical episodes are grouped within each CESLG.

This change was by far, the most impactful to TH and most likely, to many BPCI-A providers across the country. The intent, per industry experts, is to reduce clinical episode selection bias and test whether broader clinical service lines increase savings to CMS. However, it is anticipated that this change, among others for MY4, will drive a significant reduction in participation. Many BPCI-A providers, like TH, were participating in a few episodes that crossed multiple service lines. However, with the implementation of CESLGs, many providers are unable to take on the increased financial risk as well as the operational and clinical efforts necessary to be successful. Section II of this newsletter reviews the methodology used to assist each hospital’s Senior Leadership Team in considering options for MY4 participation. 

Tower Health Providers