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Preparing for the Future with BPCI Advanced: Five Things to Know


The Centers for Medicare & Medicaid Services (CMS) designed the Bundled Payments for Care Improvement (BPCI) Advanced Model to fundamentally bend the cost curve for a given episode of care, ensure greater coordination across providers and healthcare settings, and provide Medicare patients with higher-quality care. Health systems that choose to participate can benefit from aligning incentives across their hospitals, physicians and post-acute care providers.

When implemented successfully, bundled payment models are saving money and improving care at the same time. And nearly 1,300 entities are participating in the BPCI Advanced Model because they know the program is a strategic opportunity to receive positive financial rewards for success.

The BPCI Advanced Model can be a great choice to help health systems achieve future success in a value-based care delivery environment. Let’s break down the five things to know ahead of the application deadline.

1. The basics: timeline, baseline data and other details.

Participants selected to participate in the program through the upcoming application period will begin during the third model year, which starts on Jan. 1, 2020, and ends Dec. 31, 2023.

Application timeline:

  • June 24, 2019 – Last day to submit an application via the Innovation Center's Application Portal.
  • September 2019 - CMS sends data and preliminary target prices to applicants.
  • September 2019 - CMS sends participation agreement for review.
  • November 2019 - Deadline to sign and submit participation agreement and participant profile.
  • Jan. 1, 2020 - New cohort performance period begins.

Additionally, the time period for Model Year 3 baseline data is Oct. 1, 2014, to Sept. 30, 2018. However, due to data restrictions, applicants and participants will only be eligible to receive three years of baseline data. Therefore, applicants, pending submission of a Data Request and Attestation, and participants will receive baseline claims data in raw and/or summary formats, from Oct. 1, 2015, to Sept. 30, 2018.

Other details of the program include:

  • Qualifies as an Advanced Alternative Payment Model under Quality Payment Program beginning with the 2019 performance period (2021 payment).
  • All participants must accept downside financial risk from the outset of the performance period.
  • Preliminary target prices are provided in advance of the first performance period of each model year that are calculated by applying a 3 percent discount to the historical benchmark price.
  • On a retrospective basis, participants can earn either a net payment reconciliation amount (NPRA) to be paid by CMS, or may owe CMS a repayment amount, based on the actual Medicare fee-for-service expenditures for that clinical episode relative to the target price.
  • Precedence rules for episode attribution remain: (1) the physician group with the attending physician on the institutional claim; (2) the physician group with the operating physician on the institutional claim; and (3) the acute care hospital.
  • CMS will offer conditional waivers of payment policies relating to the three-day skilled nursing facility (SNF) rule, telehealth and post-discharge home visit services. CMS will also offer waivers for selected fraud and abuse laws.

2. There are four new inpatient episodes and one new outpatient episode.

CMS has added the following additional clinical episode bundle options for Model Year 3, increasing the total number of potential episode initiating clinical episodes to 37 (33 inpatient, four outpatient).

  • Bariatric Surgery (inpatient)
  • Inflammatory Bowel Disease (inpatient)
  • Seizures (inpatient)
  • Transcatheter Aortic Valve Replacement (inpatient)
  • Major joint replacement of the lower extremity (outpatient)
    • This is a multi-setting clinical episode category. Total knee arthroplasty procedures can trigger episodes in both inpatient and outpatient settings.

3. Participants may be able to use the claims-based "Administrative Quality Measures" set or an "Alternate Quality Measures" set.

Participants may be given the option to select from either the current claims-based "Administrative Quality Measures" set or an "Alternate Quality Measures" set that would include a combination of claims-based and registry-based measures.

  • Administrative Quality Measures Set: Used in Model Years 1 and 2, included only claims-based measures directly collected by CMS.
  • Alternate Quality Measures Set: Includes a combination of claims-based and registry-based measures and 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.

CMS will release additional information on the Alternate Quality Measure set prior to the close of the application period. The established Composite Quality Score calculation methodology will apply to both. All participants, regardless of the set choice, will be accountable for no more than five measures per clinical episode.

4. CMS may add a cardiac rehab incentive to the model.

CMS is considering whether to modify BPCI Advanced to incentivize the use of cardiac rehabilitation and intensive cardiac rehabilitation services for BPCI Advanced cardiac clinical episodes. The purpose is to increase utilization of cardiac rehabilitation and intensive cardiac rehabilitation services for BPCI Advanced beneficiaries.

Research has demonstrated improved long-term cardiovascular outcomes for patients who participate in cardiac rehabilitation therapy. CMS has indicated that they intend to provide further information regarding the cardiac rehabilitation incentive prior to the end of the application period (June 24, 2019).

5. Current participants can add new Episode Initiators.

The model allows two types of participants:

  • Convener Participant: Brings together multiple downstream entities referred to as "Episode Initiators" to participate in BPCI Advanced, facilitates coordination among them, and bears and apportions financial risks. Convener participants can include:
    • Eligible entities that are Medicare-enrolled providers or suppliers
    • Eligible entities that are not enrolled in Medicare
    • Acute care hospitals
    • Physician group practices
  • Non-Convener Participant: An acute care hospital or physician group practice that is not a convener participant because it bears financial risk only for itself and does not bear financial risk on behalf of multiple downstream Episode Initiators.

Current participants can add new Episode Initiators to their participation without going through the application process via the Episode Initiators Addition Template. Convener participants that would like to restructure by separating their downstream Episode Initiators into multiple agreements can submit an Episode Initiators Restructuring Template. Current applicants wishing to make modifications to provider Episode Initiators within their agreement must submit requested changes through the BPCI Advanced Participant Portal.

There’s No Time to Waste

Participating in the BPCI Advanced model can help health systems stay ahead of the shift to risk-based payment models, as well as increase revenue, manage margins and get better reimbursement. However, providers must have an essential skill set in order to engage in and prepare for these models. BPCI Advanced participation requires expertise, foresight, claims analytics capabilities and planning to develop an effective approach as well as implement gainsharing arrangements with physicians.

Premier® offers a range of expertise in bundled payment model readiness, preparation, development and implementation, including for BPCI Advanced. For more information on the second cohort of BPCI Advanced Model Year 3, watch our webinar.

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