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 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 participation in the Model on October 1, 2018, and the Model Performance Period will run through December 31, 2023. The second cohort started on January 1, 2020. At this time, CMS is not planning any additional application opportunities for the Model. You can review the Request for Applications (RFA) for Model Year 3.

Quick Links - General Information Page

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

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
  • 31 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.

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

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.

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 35 Clinical Episodes (4 Outpatient and 31 Inpatient).

Listing of Inpatient Clinical Episodes

Inpatient

Spine, Bone, and Joint

  • Back and neck except 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)**
  • Major joint replacement of the upper extremity
  • Spinal fusion*

Kidney

  • Renal failure

Infectious Disease

  • Cellulitis
  • Sepsis
  • Urinary tract infection

Neurological

  • Seizures*
  • Stroke

Cardiac

  • Acute myocardial infarction
  • Cardiac arrhythmia
  • Cardiac defibrillator
  • Cardiac valve
  • Congestive heart failure
  • Coronary artery bypass graft
  • Pacemaker
  • Percutaneous coronary intervention
  • Transcatheter Aortic Valve Replacement*

Pulmonary

  • COPD, bronchitis, asthma
  • Simple pneumonia and respiratory infections

Gastrointestinal

  • Bariatric Surgery*
  • Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis
  • Gastrointestinal hemorrhage
  • Gastrointestinal obstruction
  • Inflammatory Bowel Disease*
  • Major bowel procedure

*Indicates new Clinical Episode for Model Year 3


**This is a multi-setting Clinical Episode category. Total Knee Arthroplasty (TKA) procedures can trigger episodes in both inpatient and outpatient settings.

Listing of Outpatient Clinical Episodes

Outpatient

  • Back & neck except spinal fusion
  • Cardiac Defibrillator
  • Major joint replacement of the lower extremity (MJRLE)**
  • Percutaneous Coronary Intervention

**This is a multi-setting Clinical Episode category. Total Knee Arthroplasty (TKA) procedures can trigger episodes in both inpatient and outpatient settings.

Quality Measures

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 1-4. 

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.

Evaluations

Latest Evaluation Reports

Two Pager: At-A-Glance Report (PDF)

Additional Information

Frequently Asked Questions (FAQs) by Topic

Quality Payment Program

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.

Last updated on:
10/28/2020