BPCI Tutorial Video 3: Risk Models

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BPCI Tutorial Video 3: Risk Models

There are 4 risk models that CMS has created within BPCI.
BPCI model choices: retrospective reconciliation, prospective payments, who gets to initiate? 

Model 1

Only accounts for acute risk.

Why: Model 1 is appropriate for episode initiators who want to focus on improvements they can make within the inpatient care setting.
Who initiates: Hospitals & PGPs
Retrospective reconciliation: The payments occur as they would in the FFS world, with a retrospective reconciliation to account for any gains or losses relative to target price.
Popularity: Model 1 has only 12 participants.

Model 2

Episode is initiated with an anchor hospital admission and ends 30 / 60 or 90 days
after discharge from this anchor stay.

Why: Model 2 is the right choice for hospitals or physician practice groups that want to wield a greater influence on their patients’ wellness, following them from the hospital, through various post-acute care settings, and all the way home. The construct encourages closer collaboration between the episode initiators and various post acute providers who work together to get the patient well.
Who initiates: Hospitals & PGPs
Retrospective Reconciliation: The payments occur as they would in the FFS world, with a retrospective reconciliation to account for any gains or losses relative to target price.
Popularity: A good chunk of the BPCI participants (2,180) are in Model 2.

Model 3

Episode is initiated with a stay at a post acute facility within 30 days of discharge from
a hospital and ends 30 / 60 or 90 days after discharge from this anchor stay.

Why: PAC providers who want to achieve better patient outcomes through standardization of care after the patient is discharged from the hospital participate in Model 3.
Who initiates: PAC facilities
Retrospective Reconciliation: The payments occur as they would in the FFS world, with a retrospective reconciliation to account for any gains or losses relative to target price.
Popularity: A bulk of the BPCI participants (4,727) are in Model 2.

Model 4

Pre-calculated prospective payment is made to the episode initiator who must then manage the entire episode of acute care plus 30-day readmission within that prospective payment amount. Episode initiator must also distribute funds to each provider caring for the patient within the bundle period.

Why: Model 4 is appropriate for providers that already have at-risk arrangements, and the ability to discharge certain TPA functions.
Who initiates: Hospitals
Popularity: A handful of BPCI participants (17) are in Model 4.

 

Anita Pramoda
Truth catcher - not important that I am right, important that I find the right answer. Focus as a noun? Obsess with my customer's needs as waking thought and resting reflection. Focus as a verb? Enough to intensely iterate, but not to produce motion sickness instead of momentum.
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