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 and reduce expenditures, while improving the quality of care for Medicare beneficiaries. BPCI Advanced qualifies 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 participating in the Model on October 1, 2018. The second cohort started on January 1, 2020. The third cohort of Participants will start on January 1, 2024, and may participate until the BPCI Advanced Model period of performance ends on December 31, 2025.
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|Model Overview||Quality Measures||Key Stakeholder|
|Pricing Methodology||Clinical Episodes||Additional Information|
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
- 8 Clinical Episode Service Lines Groups starting Model Year 4 (30 Inpatient, 3 Outpatient and 1 multi-setting Clinical Episode categories)
- 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.
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.
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.
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 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.
For more information, please visit the Physician-Focused Materials section further below.
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 4, there are a total of 8 Clinical Episode Service Line Groups (30 Inpatient, 3 Outpatient and 1 multi-setting Clinical Episode categories).
Starting in Model Year 6 (2023), the BPCI Advanced Model will include Major Joint Replacement of the Upper Extremity) as a multi-setting Clinical Episode category by including outpatient Total Shoulder Arthroplasty procedure when triggered by HCPCS 23472. Therefore, in Model Year 6 there are a total of 8 Clinical Episode Service Line Groups (29 Inpatient, 3 Outpatient, and 2 multi-setting Clinical Episode categories).
- Acute Myocardial Infarction (AMI)
- Cardiac Arrhythmia
- Congestive Heart Failure
- Cardiac Defibrillator (Inpatient)
- Cardiac Defibrillator (Outpatient)
- Cardiac Valve
- Coronary Artery Bypass Graft (CABG)
- Endovascular Cardiac Valve Replacement
- Percutaneous Coronary Intervention (PCI - Inpatient)
- Percutaneous Coronary Intervention (PCI - Outpatient)
- Bariatric surgery
- Major bowel procedure
- Disorders of the Liver Except Malignancy, Cirrhosis, or Alcoholic Hepatitis
- Gastrointestinal Hemorrhage
- Gastrointestinal Obstruction
- Inflammatory Bowel Disease
Medical and Critical Care
- Chronic Obstructive Pulmonary Disease (COPD), Bronchitis, Asthma
- Renal Failure
- Simple Pneumonia and Respiratory Infections
- Urinary Tract Infection
- Back and Neck Except Spinal Fusion (Inpatient)
- Back and Neck Except Spinal Fusion (Outpatient)
- Spinal Fusion
- Double Joint Replacement of the Lower Extremity
- Fractures of the Femur and Hip or Pelvis
- Hip and Femur Procedures Except Major Joint
- Lower Extremity/Humerus Procedure Except Hip, Foot, Femur
- Major Joint Replacement of the Lower Extremity (MJRLE) (Multi-setting Inpatient/Outpatient)
- Major Joint Replacement of the Upper Extremity (MJRUE) (Multi-setting Inpatient/Outpatient)
The CMS Innovation Center’s BPCI Advanced Model rewards health care providers for delivering services more efficiently, supports enhanced care coordination, and recognizes high quality care. Hospitals and clinicians should work collaboratively to achieve these goals, which have the potential to improve the BPCI Advanced Beneficiary experience and align to the CMS Quality Strategy goals of promoting effective communication and care coordination, highlighting best practices, and making care safer and more affordable. A goal of the BPCI Advanced Model is to promote seamless, patient-centered care throughout each Clinical Episode, regardless of who is responsible for a specific element of that care.
Starting in Model Year 4, the CMS Innovation Center will provide Participants the flexibility to report quality measure performance through either an Administrative Quality Measures Set or through a clinically aligned, actionable Alternate Quality Measures Set. Up to five quality measures will apply to each Clinical Episode. To view the list of available fact sheets specific to each measure, please visit the Quality Measures Fact Sheet page for Model Years 1-5.
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.
Latest Evaluation Reports
- Two-Pager: At-A-Glance Report (PDF)
- Two Pager: At-A-Glance Report (PDF)
Prior Evaluation Reports
- Two-Pager: At-A-Glance Report (PDF)
- Two Pager: At-A-Glance Report (PDF)
- BPCI Advanced Model Extension and Changes for Model Year 6 Fact Sheet (PDF)
- Model Overview Fact Sheet- Model Year 6 (PDF)
- BPCI Advanced Data Crosswalk (ZIP) (updated 9/27/2022)
- BPCI Advanced Participants - MY5 (XLS)
- Episode Initiators and Clinical Episode Service Line Group Selections - MY5 (XLS)
- Clinical Episodes to Quality Measures Correlation Table - MY4 (PDF)
- Clinical Episodes to Quality Measures Correlation Table - MY5 (PDF)
- Quality Measures Fact Sheet page
- SNF Waiver List - Q4 2022 (XLS)
- Webinar: Model Overview MY3: Audio (MP4) | Slides (PDF) | Transcript (PDF)
- Webcast: Model Overview MY3: Audio (MP4) | Slides (PDF) | Transcript (PDF)
- Webcast: Quality Methodology MY3: Audio (MP4) | Slides (PDF) | Transcript (PDF)
- BPCI Advanced Reflect and Reset Infographic – MY5 CRP Takeaways (PDF)
- Archived Materials
Frequently Asked Questions (FAQs) by Topic
- General FAQs (PDF) - updated November 2022
- Data FAQs (PDF) - updated November 2022
- Quality Measures FAQs (PDF)
- Pricing Methodology FAQs (PDF) - updated November 2022
- Model Overlap FAQs (PDF) - updated November 2022
- Attribution-Eligible Beneficiaries under the Quality Payment Program Fact Sheet (PDF)
- BPCI Advanced/QPP FAQs (PDF)
- Webinar: QPP Intersection with BPCI Advanced Part I: Slides (PDF) | Transcript (PDF) | Audio (MP4)
- Physician Fact Sheet (PDF)
- Physician Frequently Asked Questions (PDF)
- Patient Experience in FFS vs. Bundled Payments - Cardiology (mp4)
- Patient Experience in FFS vs. Bundled Payments – Surgical (mp4)
- Quality Measures Fact Sheet page
- Webcast: Conceptual Overview (2018) - Audio (mp4) | Slides (PDF) | Transcript (PDF)
- Webcast: Operationalizing BPCI (2018) - Audio (mp4) | Slides (PDF) | Transcript (PDF)
Information for Participants
Please visit the Participant Resources page for additional materials geared towards organizations or individuals actively participating in the Model.