bundled payments

Welcoming the Healthcare of 2019 with BPCI Advanced and InCK Models

Abhinav Shashank
Tue 18 December 2018

In order to support its goal of fostering affordable, accessible healthcare, CMS announced a new voluntary episode payment model, known as Bundled Payments for Care Improvement Advanced (BPCI Advanced or the Model). The model will test a new iteration of bundled payments for 32 Clinical Episodes, aiming to align incentives among participating providers in hopes of reducing expenditures and improving quality of care.

One step ahead with CMS BPCI Advanced

BPCI Advanced will qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program. BPCI Advanced will require downside financial risk of all participants from the outset of the Model Performance Period. The eligible members can:

  • Participate as a Non-Convener Participant:
    • Acute Care Hospitals (ACHs)
    • Physician Group Practices (PGPs)
  • Participate as a Convener Participant:
    • Eligible entities that are Medicare-enrolled providers or suppliers
    • Eligible entities that are not enrolled in Medicare
    • Acute Care Hospitals (ACHs)
    • Physician Group Practices (PGPs)

CMS has selected seven quality measures for the BPCI Advanced Model. Two of them, an All-Cause Hospital Readmission Measure and Advance Care Plan, will be required for all Clinical Episodes.

Setting up the background of child health care in the United States

When it comes to defining the most suitable care plan for children, most of us are left scratching our heads trying to find the right answer. With insurance programs such as the Children’s Health Insurance Program (CHIP), the government is able to provide comprehensive benefits to children. Medicaid Expansion CHIP programs offer some additional benefits along with a standard Medicaid benefit package including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, among others.

In 2009, the Children’s Health Insurance Reauthorization Act (CHIPRA) extended and reauthorized the Children’s Health Insurance Program (CHIP). 46 states and the District of Columbia cover children up to 200% of the Federal Poverty Level (FPL), and 24 of these states offer coverage to children in families with income at or above 250% of the FPL.

States can choose to provide benchmark coverage, benchmark-equivalent coverage, or Secretary-approved coverage under the CHIP benefits options:

  • Benchmark coverage based on one of the following:
    • The standard Blue Cross/Blue Shield preferred provider option service benefit plan offered to federal employees
    • State employee coverage plan
    • HMO plan that has the largest commercial, non-Medicaid enrollment within the state
  • Benchmark-equivalent coverage must be actuarially equivalent and include:
    • Inpatient and outpatient hospital services
    • Physician’s services
    • Surgical and medical services
    • Laboratory and X-ray services
    • Well-baby and well-child care, including immunizations
  • Secretary-approved coverage: Any other health coverage deemed appropriate and acceptable by the Secretary of the U.S. Department of Health and Human Services.

Moving forward with the new domains of future care delivery

Continuing with their trend to provide holistic care to the US population, the Centers for Medicare and Medicaid Innovation (Innovation Center) announced a new model— The Integrated Care for Kids (InCK) Model. The model is tested under the authority of section 1115A of the Social Security Act.

It is child-centered local service delivery and state payment model aimed at reducing expenditures and improving the quality of care for children covered by Medicaid and CHIP.

Source: Shutterstock

Why is developing a new model for children important?

The care for children varies from that of adults. Behavioral health conditions among children drive a significant percentage of morbidity, over-utilization of healthcare resources, and poor status of overall health outcomes. Additionally, there has been a high rate of opioid use and other substances among youth populations when compared to adults.

According to a 2015 Annual Report on the Quality of Care for Children in Medicaid and CHIP, one in three children enrolled in Medicaid and CHIP have behavioral health needs and these facilities are accessed by only one-third of them. Prescription drug misuse, including opioids, is among the fastest growing drug problem in the United States. In 2016, 3.6% of children under the age of 12 to 17 years were reported to be misusing opioids during the previous year. This number is twice as high among older adolescents and young adults aged 18 to 25.

Source: Key Substance Use and Mental Health Indicators in the United States:
Results from the 2016 National Survey on Drug Use and Health

The current healthcare system for children is facing challenges in identifying and addressing risk factors for behavioral health conditions; this is mostly due to the misinterpretation of the earliest signs of a problem to be considered outside of clinical care such as chaotic family situations, behavioral problems in schools, and many more. Even though we have multiple federal and state policies to provide support in understanding such behavioral aspects of children, limited information sharing is still a major roadblock in bringing children and their families to the center of their care.

How could the Integrated Care Model be the solution?

The InCK model will be awarding states and local communities the opportunity to build on existing delivery system innovations with the goals of:

  • Improving child health outcomes including the prevention of substance use disorders
  • Reducing avoidable inpatient stays and out-of-home placements, including substitute care
  • Creating sustainable APMs that can ensure provider accountability for cost and quality outcomes

The key participants of the model will be the state Medicaid agency and a local entity known as a “Lead Organization.” State Medicaid agencies will be responsible for supporting local implementation by providing population-level data for the geographic service area. On the other hand, lead organizations will convene community partners to integrate the coordination and management of InCK’s core child services.

Source: CMS Webinar: Integrated Care for Kids (InCK) Model

The participants will be building a strong community capacity to provide more effective, efficient, and affordable care through home and community-based services (HCBS) to reduce avoidable inpatient stays and out-of-home placements. The Centers for Medicare and Medicaid Services (CMS) will be awarding up to 8 states. In this arrangement, either a State Medicaid Agency or a Lead Organization will be receiving the award of a cooperative agreement.

What are the key design elements of the model?

The model focuses on serving all children covered by Medicaid and CHIP, from the prenatal period to the age of 21 years. It primarily consists of the following design elements:

  • Core child services
  • Service integration
  • Risk stratification approach and tiered service delivery
  • Alternative payment models

Let us now discuss every design element in sequential order.

  • Core Child Services

Core child services will include all the primary basic needs for providing proper and apt care to children. Lead organizations will be coordinating the integration of these services. These services include clinical care (physical and behavioral), early care and education, schooling and housing facilities, child welfare, food, mobile crisis response services, and others. However, lead organizations may also consider including other service types, as deemed appropriate.

  • Service Integration

The model offers the lead organizations and their partner communities the flexibility to employ the most appropriate and convenient service integration strategies for achieving the model’s aim in the local context. Service integration design consists of six key characteristics that the lead organizations or the state Medicaid agencies need to incorporate in their implementation plan. These characteristics include:

Source: CMS Integrated Care for Kids Model Factsheet

  • Risk Stratification Approach and Tiered Service Delivery

The structure of the model’s service integration is based on the population-wide risk-stratification according to the level of need. The levels of service integration, known as SILs, consist of an integrated care coordination and case management to increase intensity which is appropriate for addressing individual needs. The primary goal of risk stratification is to ensure that children receive the personalized care that they deserve in the most integrated and least restrictive setting possible.

Source: CMS Integrated Care for Kids Model Factsheet

There are basically three levels of service integration. SIL 1 includes all children who are covered by Medicaid and CHIP up to the age of 21 years and who are residents of either a lead organization’s or a state Medicaid agency’s geographic service area. However, SIL 2 and SIL 3 serve multi-sector needs, functional impairments, and those who are at risk of being placed outside of their homes.

  • Alternative Payment Models

States will work with CMS and Lead Organizations to design and implement one or more child-focused APMs in Medicaid and CHIP, if applicable. States with existing APMs may instead alter as necessary to meet the model’s criteria. The model will require participating states to develop APMs for supporting care coordination, case management, and mobile crisis response and stabilization services via existing state authorities available under Medicaid/CHIP. The primary goals of APMs are:

  • To promote accountability for improved outcomes, such as rates of avoidable out-of-home placement and opioid use
  • To ensure the model’s long-term sustainability

The future with the Integrated Care for Kids Model

The Integrated Care for Kids Model will include a two-year pre-implementation period. During this period, CMS will work with state Medicaid agencies and lead organizations to establish their Medicaid and CHIP authorities and develop the infrastructure necessary for the implementation of the model. It will be followed by a five-year model implementation period in which the state agencies and the lead organizations will be implementing their models and reporting required data to CMS.

The road ahead

The Centers for Medicare and Medicaid Services (CMS) has worked with the Centers for Disease Control (CDC) on issuing joint guidance for all states with a separate CHIP program on providing proper care to children. As a part of the government’s multi-pronged strategy to reduce the opioid misuse and deliver the right care, the Integrated Care for Kids Model will offer states and local providers support to address these priorities through a framework of child-centered care integration across behavioral, physical, and other areas of medicine. With these innovative approaches such as InCK and BPCI Advanced, CMS is rapidly moving towards the goal of providing affordable and accessible healthcare.


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