BPCI Advanced

The Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model is a new iteration of the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (Innovation Center) continuing efforts in implementing voluntary episode payment models. The Model aims to support healthcare providers who invest in practice innovation and care redesign to better coordinate care, improve quality of care, and reduce expenditures, while improving the quality of care for Medicare beneficiaries. BPCI Advanced will qualify as an Advanced Alternative Payment Model (APM) under the Quality Payment Program.

The overarching goals of the BPCI Advanced Model are: Care Redesign, Health Care Provider Engagement, Patient and Caregiver Engagement, Data Analysis/Feedback and Financial Accountability.

The first cohort of Participants started participation in the Model on October 1, 2018, and the Model Performance Period will run through December 31, 2023. The second cohort will start on January 1, 2020. The application period for the second cohort is currently open and will close on June 24, 2019. At this time, CMS is not planning any additional application opportunities for the Model. You can review the Request for Applications and the Application template for Model Year 3 in the Applicant Resources web page.

If you are interested in receiving additional information about BPCI Advanced, announcements of upcoming events and future application opportunities, please sign up for the BPCI Advanced listserv.

Quick Links - General Information Page

Model Overview Quality Measures Key Stakeholder
Pricing Methodology Clinical Episodes Additional Information

Quick Links - Other Pages

Participant Resources Applicant Resources

Background

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.

Select anywhere on the map below to view the interactive version BPCI Advanced

Model Overview

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
  • 33 Inpatient Clinical Episodes starting Model Year 3
  • 4 Outpatient Clinical Episodes starting Model Year 3
  • Qualifies as an Advanced Alternative Payment Model (AAPM)
  • Payment is tied to performance on Quality Measures
  • Preliminary Target Prices provided prior to each Model Year

The BPCI Advanced Model 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.

Key Stakeholders

Participants

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. There are two categories of Participants: Convener Participants and Non-Convener Participants.

A Convener Participant is a type of Participant that brings together at least one entity referred to as “Downstream Episode Initiators” (Downstream EIs)—which must be either Acute Care Hospitals (ACHs) or Physician Group Practices (PGPs)—to participate in BPCI Advanced, facilitate coordination among them, and bear and apportion financial risks.  Convener Participants enter into agreements with the EIs, whereby EIs agree to participate in BPCI Advanced and comply with all applicable Model requirements.

Can participate as a Non-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 Non-Convener Participant is the Episode Initiator (EI) that bears financial risk only for itself and does not have any Downstream EIs. Only PGPs and ACHs may participate in BPCI Advanced as a Non-Convener Participant.

Can participate as a Non-Convener Participant:

  • Acute Care Hospitals (ACHs)
  • Physician Group Practices (PGPs)

An EI is a Medicare-enrolled provider or supplier that can trigger a Clinical Episode under BPCI Advanced. In this Model, EIs can only be PGPs or ACHs, including ACHs where outpatient procedures are performed in hospital outpatient departments (HOPDs).

Physicians

Physicians are ideally positioned to direct high-value, patient-centered care, and they are crucial to the success of BPCI Advanced. The model emphasizes specialty physician engagement and provides resources to facilitate peer-to-peer learning.

Beneficiaries

BPCI Advanced is testing a different approach for health care delivery: a new voluntary bundled payment model that links physician, hospital and post-acute care payments into a bundled clinical episode for the hospital stay, or outpatient procedure, and 90 days post discharge. These Clinical Episodes are assessed for the quality and cost of care provided to each beneficiary. Participants may earn additional payments from Medicare, but may owe money back to Medicare, if costs are higher than expected.

CMS recognizes the importance of beneficiaries being aware that their medical providers are participating in the BPCI Advanced Model. Therefore, all Participants, Episode Initiators and Participating Practitioners in the Model must provide a BPCI Advanced Beneficiary Notification Letter to Medicare beneficiaries that might trigger a Clinical Episode prior to discharge from the hospital or prior to the completion of an outpatient procedure, as applicable. In addition, Participants may not restrict beneficiary choice of providers or suppliers.

BPCI Advanced shifts the emphasis from a series of individual services toward a cohesive, bundled clinical episode. While care continues to be delivered on a fee-for-service basis, an accountable party, in this case the Participant in the Model, takes responsibility for coordinating care during the hospitalization or outpatient procedure and 90 days afterwards.

Beneficiaries will have the same cost-sharing responsibility for services received from a Medicare provider or supplier participating in BPCI Advanced. As with all CMS Innovation Center models, we will monitor BPCI Advanced to guard against any unintended consequences that might negatively impact beneficiaries.

Beneficiaries will retain their freedom to choose any provider or supplier and, if they feel their care has been compromised, they should call 1-800-MEDICARE or contact their Quality Improvement Organizations (QIO).

Clinical Episodes

A BPCI Advanced Clinical Episode is structured to begin either at the start of an inpatient admission (the Anchor Stay) to an Acute Care Hospital (ACH) or at the start of an outpatient procedure (the Anchor Procedure). Inpatient admissions that qualify as an Anchor Stay will be identified by Medicare Severity-Diagnosis Related Group (MS-DRGs) codes, while outpatient procedures that qualify as an Anchor Procedure will be identified by Healthcare Common Procedure Coding System (HCPCS) codes. The Clinical Episode length will be the Anchor Stay plus 90 days beginning the day of discharge or the Anchor Procedure plus 90 days beginning on the day of completion of the outpatient procedure. Clinical Episodes are constructed to include all services that overlap the Clinical Episode window, with some exclusions.

Starting Model Year 3, there are a total of 37 Clinical Episodes (4 Outpatient and 33 Inpatient).

Listing of the Clinical Episodes

Quality Measures

CMS has selected seven Administrative Quality Measures for the BPCI Advanced Model Years 1 & 2 (2018 & 2019). Three of them, All-cause Hospital Readmission Measure, Advance Care Plan, and the CMS Patient Safety Indicators will be required for all Clinical Episodes. The other four quality measures will only apply to select Clinical Episodes.

For quality measure reporting in Model Year 3, we may be providing Participants the flexibility to choose either the Administrative Quality Measures Set used in Model Years 1 and 2 (2018 and 2019, respectively) or an Alternate Quality Measures Set. The Administrative Quality Measures Set may include exclusively claims-based measures directly collected by CMS. The Alternate Quality Measures Set includes a combination of claims-based and registry-based measures.  The Alternate Quality Measures Set was developed after CMS gathered information on various established registries to identify a tailored set of quality measures that align with each of the specialty-specific Clinical Episodes in the Model.

Episode Initiators will be required to commit to either the Administrative Quality Measures Set or the Alternate Quality Measures Set in advance of participation in Model Year 3 which begins on January 1, 2020. The established Composite Quality Score (CQS) calculation methodology will apply to both measure sets..

CMS may determine whether additional quality measures should be incorporated into the Administrative Quality Measures Set or the Alternate Quality Measures Set in future Model Years and the quality measures may be updated by CMS on an annual basis.

We anticipate making public the list of Alternate Quality Measures for Model Year 3 available prior to the close of the application period on June 24, 2019. The Fact Sheets for the current seven Administrative Quality Measures are posted below and the Fact Sheets for the new Alternate Quality Measures Sets will be made available at a later time.

Fact Sheets for each of the Administrative Quality Measures for Model Years 1, 2 and 3

To view the full list of available fact sheets, please visit the BPCI Advanced Administrative Quality Measures for Model Years 1, 2 and 3 Fact Sheets web page.

Pricing Methodology and Payment

The BPCI Advanced Model uses a retrospective bundled payment approach. Specifically, under BPCI Advanced, CMS may make payments to Model Participants or Model Participants may owe a payment to CMS after CMS reconciles all non-excluded Medicare FFS expenditures for a Clinical Episode against a Target Price for that Clinical Episode. The Target Price calculations, Reconciliation calculations, and attribution of Clinical Episodes to Participants will each occur at the Episode Initiator (EI) level.

CMS has developed a large number of technical resources providing guidance on this topic. Please visit the Participants Resources web page.

How to Contact the BPCI Advanced Team

If you have questions regarding the Model, you can contact the BPCI Advanced team by emailing BPCIAdvanced@cms.hhs.gov.

Additional Information

FAQs by Topic

Physician-Focused Materials

Information for Participants

Please visit the Participant Resources page for additional materials geared towards organizations or individuals actively participating in the Model.

Information for Applicants

Please visit the Applicant Resources page for additional materials geared towards organizations or individuals considering applying for the Model in 2019.