BPCI Advanced: 10 Things to Know About the New BPCI Advanced Program

DATE: 01/10/2018

What you should be aware of—and what you can do now


After months of waiting, the Centers for Medicare and Medicaid Services (CMS) released its new voluntary episode model, Bundled Payments for Care Improvement Advanced (BPCI Advanced), which begins October 1, 2018. DataGen’s policy analysts are currently assessing the model as a whole. Participants—both current and potential—need to understand what is contained in this new version and what it means for them. Here are the three key things you should do first:

  1. Request your data. This doesn’t obligate your participation, but your data are foundational to assessing what you may be able to do in the new programs.
  2. Evaluate risks and opportunities. Take a look at where your volumes are high, where you may be able to streamline post-acute care, and how you can reduce complications.
  3. Assess strategic buy-in. Try to understand how supportive other organizational stakeholders may be about participation—and what their appetite is for participating in the first place.

Once you’ve taken stock of those three items, you need to be aware of 10 factors:

  1. If you’re currently participating in the Comprehensive Care for Joint Replacement (CJR) program, you cannot participate for those Diagnosis-Related Groups (DRGs) in BPCI Advanced.
  2. The majority of episodes were a part of the BPCI initial program, with the addition of three outpatient surgical procedures.
  3. Physician Group Practices (PGPs) or hospitals can own episodes; PGPs get precedence, and Post-Acute Care (PAC) groups are not included as initiators.
  4. We know that the structure of acute-care DRGs will be similar to the previously defined ones: an episode starts with acute admission and includes the 90-day post-discharge along with a 30-day post-episode spending monitoring period. Episodes will include all Part A and Part B services, with some exclusions.
  5. Protections are included for outlier episodes.
  6. There is immediate downside risk and only one risk track, with a 3% target discount.
  7. Performance targets will be based on providers’ historic experience, not regional benchmarks.
  8. This program will qualify as an advanced alternative payment model (APM) under the Merit-based Incentive Payment System (MIPS)
  9. Gainsharing is allowed with physicians and other downstream providers.
  10. Quality measures are tied to financial outcomes, but the details on quality scoring methodologies are not yet available.

There are still a few uncertainties following our initial assessment. For example, the specifics of how episodes are constructed—particularly outpatient surgery episodes—are unclear. When will applicants receive their historic baseline data? This is critical—if these data come across too late, reviewing opportunities and risks will require additional resources.

In addition, it’s not clear what the baseline time period is. The Data Request Attestation (DRA) appears to be a four-year period, but this is inconsistent with prior programs. We will be evaluating these changes in more depth in the coming weeks. In the meantime, please visit for more coverage on the impacts of BPCI Advanced.

Tags: , , ,