The Centers for Medicare & Medicaid Services (CMS) Center for Medicare and Medicaid Innovation (Innovation Center) is announcing a new voluntary episode payment model, Bundled Payments for Care Improvement Advanced (BPCI Advanced or the Model) that will test a new iteration of bundled payments for 32 Clinical Episodes and aim to align incentives among participating health care providers for reducing expenditures and improving quality of care for Medicare beneficiaries. BPCI Advanced will qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.
The first cohort of Participants will start participation in the Model on October 1, 2018, and the Model Period Performance will run through December 31, 2023. CMS will provide a second application opportunity in January 2020.
One of the most important goals at CMS is fostering an affordable, accessible healthcare system that puts patients first. A bundled payment methodology involves combining the payments for physician, hospital, and other health care provider services into a single bundled payment amount. This amount is calculated based on the expected costs of all items and services furnished to a beneficiary during an episode of care. Payment models that provide a single bundled payment to health care providers can motivate health care providers to furnish services efficiently, to better coordinate care, and to improve the quality of care. Health care providers receiving a bundled payment may either realize a gain or loss, based on how successfully they manage resources and total costs throughout each episode of care. A bundled payment also creates an incentive for providers and suppliers to coordinate and deliver care more efficiently because a single bundled payment will often cover services furnished by various health care providers in multiple care delivery settings.
BPCI-Advanced is defined by following characteristics:
- Voluntary Model
- A single retrospective bundled payment and one risk track, with a 90-day Clinical Episode duration
- 29 Inpatient Clinical Episodes
- 3 Outpatient Clinical Episodes
- Qualifies as an Advanced APM
- Payment is tied to performance on quality measures
- Preliminary Target Prices provided in advance of the first Performance Period of each Model Year
BPCI Advanced aims to encourage clinicians to redesign care delivery by adopting best practices, reducing variation from standards of care, and providing a clinically appropriate level of services for patients throughout a Clinical Episode.
BPCI Advanced will operate under a total-cost-of-care concept, in which the total Medicare fee for services (FFS) spending on all items and services furnished to a BPCI Advanced Beneficiary during the Clinical Episode, including outlier payments, will be part of the Clinical Episode expenditures for purposes of the Target Price and reconciliation calculations, unless specifically excluded.
For purposes of BPCI Advanced, a Participant is defined as an entity that enters into a Participation Agreement with CMS to participate in the Model. BPCI Advanced will require downside financial risk of all Participants from the outset of the Model Performance Period.
Can participate as a Non-Convener Participant:
- Acute Care Hospitals (ACHs)
- Physician Group Practices (PGPs)
Can 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)
A Convener Participant is a type of Participant that brings together multiple downstream entities, referred to as “Episode Initiators (EIs).” A Convener Participant facilitates coordination among its EIs and bears and apportions financial risk under the Model.
A Non-Convener Participant is a Participant that is in itself an EI and does not bear risk on behalf of multiple downstream Episode Initiators.
BPCI Advanced will initially include 29 inpatient Clinical Episodes and 3 outpatient Clinical Episodes. Based on rapid-cycle feedback and experience to date in the initiative, CMS may elect to revise the Clinical Episodes in BPCI Advanced on an annual basis beginning January 1, 2020, which will apply to both new Participants and existing Participants. Participants selected to participate in BPCI Advanced beginning on October 1, 2018, must commit to be held accountable for one or more Clinical Episodes and may not add or drop such Clinical Episodes until January 1, 2020.
For a list of the 29 Inpatient Clinical Episodes, please see below:
- Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis *
*(New episode added to BPCI Advanced)
- Acute myocardial infarction
- Back & neck except spinal fusion
- Cardiac arrhythmia
- Cardiac defibrillator
- Cardiac valve
- Cervical spinal fusion
- COPD, bronchitis, asthma
- Combined anterior posterior spinal fusion
- Congestive heart failure
- Coronary artery bypass graft
- Double joint replacement of the lower extremity
- Fractures of the femur and hip or pelvis
- Gastrointestinal hemorrhage
- Gastrointestinal obstruction
- Hip & femur procedures except major joint
- Lower extremity/humerus procedure except hip, foot, femur
- Major bowel procedure
- Major joint replacement of the lower extremity
- Major joint replacement of the upper extremity
- Percutaneous coronary intervention
- Renal failure
- Simple pneumonia and respiratory infections
- Spinal fusion (non-cervical)
- Urinary tract infection
For a list of the 3 Outpatient Clinical Episodes, please see below:
- Percutaneous Coronary Intervention (PCI)
- Cardiac Defibrillator
- Back & Neck except Spinal Fusion
In BPCI Advanced, Clinical Episodes will be attributed at the EI level. The hierarchy for attribution of a Clinical Episode among different types of EI is as follows, in descending order of precedence: (1) the PGP that submits a claim that includes the National Provider Identifier (NPI) for the attending physician; (2) the PGP that submits a claim that includes the NPI of the operating physician; and (3) the ACH where the services that triggered the Clinical Episode were furnished. BPCI Advanced will not use time-based precedence rules.
A BPCI Advanced Clinical Episode is structured to begin either at the start of an inpatient admission to an ACH (the Anchor Stay) or at the start of an outpatient procedure (the Anchor Procedure). Inpatient admissions that qualify as an Anchor Stay will be identified by MS-DRGs, while outpatient procedures that qualify as an Anchor Procedure will be identified by HCPCS codes. The Clinical Episode will end 90 days after the end of the Anchor Stay or the Anchor Procedure.
Reconciliation will be a semi-annual process where CMS will compare the aggregate Medicare FFS expenditures for all items and services included in a Clinical Episode against the Target Price for that Clinical Episode to determine whether the Participant is eligible to receive a payment from CMS, or is required to pay a Repayment Amount to CMS.
CMS has selected seven quality measures for the BPCI Advanced Model. Two of them, All-cause Hospital Readmission Measure and Advance Care Plan, will be required for all Clinical Episodes. The other five quality measures will only apply to select Clinical Episodes.
- All-cause Hospital Readmission Measure (NQF #1789)
- Advanced Care Plan (NQF #0326)
- Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF #0268)
- Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF #1550)
- Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF #2558)
- Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (NQF #2881)
- AHRQ Patient Safety Indicators (PSI 90)
How to Apply
The Request for Applications (RFA) for BPCI Advanced was released on January 9, 2018 and it outlines the different elements of the Model in detail and explains how the applications will be reviewed. The RFA is now available (PDF).
An application template and all the additional required documents are available below:
- Application template (PDF)
- Attachment 1 – Data Request and Attestation (DRA) Form (PDF)
- Attachment 2 – Participating Organizations List (XLS)
- Attachment 3 – PGP Practitioners List (XLS)
The actual application and all required documents must be submitted via the BPCI Advanced Application Portal. The Portal opened on January 11, 2018 and close on March 12, 2018 at 11:59 pm EST.
Questions regarding the BPCI Advanced Model can be directed to BPCIAdvanced@cms.hhs.gov.
- Press Release
- Fact Sheet (PDF)
- Roadmap - Model Timeline (PDF)
- Frequently Asked Questions (FAQs) (PDF)
- Episode Definitions - Model Year 1 (XLS)
- MS-DRGs Exclusions from Clinical Episodes List (XLS)
- Comparison Table of Bundled Payment Models (PDF)
- BPCI Advanced Request for Applications (RFA) (PDF)
- BPCI Advanced Application template (PDF)
- BPCI Advanced Application Process Hand Out (PDF)
- Application Attachment - Data Request and Attestation (DRA) Form (PDF)
- Application Attachment - Participating Organizations (XLS)
- Application Attachment - PGP Practitioners List (XLS)
Open Door Forum - Q&A Session