BPCI-Advanced: Best Practices for Participants and New Applicants

As part of a larger initiative to reform healthcare delivery and payments and increase adoption of value-based care, The Centers for Medicare and Medicaid Services (CMS) introduced the Bundled Payments for Care Improvement – Advanced (BPCI-A) Model in 2018. This voluntary episode payment model falls under the Quality Payment Program as an Advanced Alternative Payment Model (APM).

The program was originally slated to end December 31, 2023. However, due to a recent two-year extension, providers have an opportunity to apply to participate beyond calendar year 2023. The BPCI-A program is now scheduled to end December 31, 2025.

Read on to learn about the BPCI-A program, some challenges participants face, and how technology can support success.

What is BPCI-A?

The BPCI-A program leverages innovative payment strategies to promote lower expenditures and improved quality care for Medicare fee-for-service (FFS) beneficiaries. It is a total cost-of-care model, in which expenditures for all services furnished during the Clinical Episode are compared to a target price. This approach encourages clinicians to work collaboratively, adhere to best practices, and provide clinically appropriate, cost-appropriate care throughout the entire care episode.

In this model, the key goals include:

• Care coordination
• Financial accountability
• Data analysis and feedback
• Health care provider engagement
• Beneficiary engagement

Providers interested in participating in the new model cohort beginning January 1, 2024 should respond to CMS’s Request for Applications (RFA) before May 31, 2023.

Who is eligible to apply for BPCI-A?

The RFA for BPCI-A is open to both returning and new participants. There are two categories of participants that may apply:

• Conveners – this type of participant brings together a minimum of one downstream Episode Initiators (EIs). These EIs may be Acute Care Hospitals (ACHs) and/or Physician Group Practices (PGPs). Conveners facilitate coordination between EIs and assign financial risk.
• Non-conveners – these are PGPs or ACHs that bear financial risk only for themselves, not for downstream EIs.

In this model, EIs may only be PGPs or ACHs that are Medicare-enrolled.

How does BPCI-A work?

BPCI-A participants can choose among a specific set of clinical episodes, for which they are held accountable for cost and quality of care. There are eight total Clinical Episode Service Line Groups that cover 34 clinical episodes included in BPCI-A. They are as follows:

• Cardiac care
• Cardiac procedures
• Gastrointestinal care
• Gastrointestinal surgery
• Neurological care
• Medical and critical care
• Spinal procedures
• Orthopedics

Clinical Episodes are anchored to an inpatient stay or outpatient procedure and last for 90 days. Throughout the episode, participating providers continue to bill for services under the traditional FFS system. The services furnished within each 90-day episode are “bundled” together and twice per year, aggregated claims paid are compared against a pre-determined target price for the clinical episode.

If the actual claims paid are lower than the target price, providers may be eligible to receive a portion of the surplus. However, if aggregated payments received exceed the target price for the clinical episode, then the participant may be required to pay a portion of the difference. This creates an incentive for the BPCI-A participant to ensure the broader care team across healthcare settings is communicating and collaborating to provide efficient, high-quality care.

For example, a hospital that is an Episode Initiator for a major joint replacement clinical episode would not only want to ensure that care delivered within their four walls is cost effective, but also focuses on the post-acute portion of a patient’s episode. If the patient goes to a skilled nursing facility (SNF) for rehab, are they staying an appropriate number of days? Are downstream partners, including the SNF, home health, and physician care team members following best practices related to care transitions and follow up to minimize the patient’s risk of hospital readmission?   

In addition to comparing the total cost of care to a target price for the episode, quality measures help determine whether outcomes are successful. These quality measures are defined by two sets — the administrative quality measures set and the alternate quality measures set. EIs must commit to one of the set types at the beginning of each model year.

Barriers to success in BPCI-A

Participants in BPCI-A face common challenges in delivering care for improved patient outcomes and reduced costs. Providers and participants in the BPCI-A program share several common goals to improve the overall quality of care while reducing overall cost. These include, reducing avoidable readmissions, managing SNF utilization, and improving collaboration among providers across the care continuum.

BPCI-participants face various challenges related to care transitions and coordination, such as:

• Poor handoffs when patients move between settings, such as from a hospital to a post-acute facility, leading to readmissions
• Difficulty tracking patient movement throughout a care episode
• Inability to monitor and influence SNF length of stay
• Limited awareness of patient progress and risks during a SNF stay
• Lack of timely insights on utilization and cost trends due to reliance on lagged claims data

One reason these areas can be difficult to impact is because the IT landscape across the healthcare industry is fragmented. Despite progress towards interoperability, data still largely sits in silos, with IT systems unable to easily communicate with each other and exchange patient information. However, by leveraging the right health IT solutions for bundled payment models, BPCI-A participants overcome these challenges.

Technology-driven strategies for improving performance in BPCI-A

Capabilities that help streamline, automate, and connect critical patient data across the care continuum can help BPCI-A participants —and participants in other value-based payment arrangements, such as ACOs— overcome these challenges. Consider the following health IT-driven possibilities:

• Shared patient care plans – individual patient care plans and insights shared across the entire care team, regardless of the electronic medical record used, enabling  more informed care decisions
• Criteria-based encounter alerts – tracking of priority populations and surfacing high-risk patients  
• Bi-directional clinical data – transitions of care that are supported with acute and post-acute encounter data and clinical data, when and how you need it
• Automated, real-time dashboards – ability to understand performance on metrics such as readmissions and SNF length of stay, identify drivers, and take action sooner than waiting for claims data

Additionally, facilitating better care transitions and coordination between hospitals, ACOs, and SNFs can support quality and outcome improvement goals. Solutions available can include features and functionality such as real-time patient monitoring, improved exchange of clinical data, sophisticated readmission risk alerts, and analytical dashboards and scorecards.

Whether re-enrolling in BPCI-A or applying to join for the first time, you can benefit from alleviating blind spots in care and empowering your organization to make sound decisions that contribute to better health and financial outcomes.