BPCI Advanced

The Centers for Medicare and Medicaid Services (CMS) is rolling out its latest value-based payment model, BPCI Advanced, starting October 1st 2018 as it continues its efforts to lower healthcare costs in the United States by incentivizing health care providers to utilize services more efficiently and coordinate care more effectively. Like most of the previous value-based models, enrollment in BPCI Advanced is completely voluntary for participants.

How is BPCI Advanced different from other BPCI models?

BPCI Advanced differs from BPCI Classic in several key ways

  1. Fewer Episode Initiators
    In BPCI Advanced, only acute care hospitals (ACH) and physician group practices (PGP) can participate as Episode Initiators. Previous BPCI models allowed for home health agencies (HHA), skilled nursing facilities (SNF), and other post-acute care providers to serve as Episode Initiators.
  2. Fewer Clinical Episodes
    BPCI Advanced will include fewer clinical episodes (29 Inpatient Episodes and 3 Outpatient Episodes) than previous BPCI models (Models 2, 3 and 4 all included 48 Inpatient Episodes). For the first time ever, the DRG episode list will include three outpatient clinical episodes.
  3. Target Price Calculation
    BPCI Classic provided target costs at reconciliation, based on historical spend and regional targets. BPCI Advanced will involve target prices that are determined prospectively and include case-mix adjustments that are based on over 100 factors. In other words, the actual target price for any given patient will be more variable than in past models.CMS is also introducing a ‘peer-adjusted trend factor’ to BPCI Advanced’s target price methodology, meaning that participating groups are no longer only competing against their own historical values, but also the other participants in their peer groups. It is now more important than ever for Episode Initiators to proactively experiment with redesigned workflows and emerging technologies in order to continue to improve upon historical baselines.
  4. Semi-Annual Reconciliation
    Under previous BPCI models, participants were able to assess their performance on a quarterly basis with reconciliation data provided by CMS. For BPCI Advanced, participants will receive reconciliation reports bi-annually.
  5. New, One-Time “No-Risk” Offer
    CMS will now be allowing a one-time opportunity for all participants to retroactively withdraw Episode Initiators (EIs) and/or Clinical Episodes in March 2019. CMS also clarified that participants that retroactively withdraw EIs and/or Clinical Episodes will not be held accountable (e.g., no risk) for withdrawn episodes triggered during Model Years 1 and 2 (e.g., any episodes initiated on or after October 1).This allows participants to elect any (or all) clinical conditions to buy more time to prepare their teams, further review baseline data and qualitatively monitor progress in their bundles of interest. This is a significant advantage to potential participants in BPCI Advanced.

Which clinical episodes are covered?

Inpatient Clinical Episodes

  • Disorders of the liver excluding malignancy, cirrhosis, alcoholic hepatitis *(New episode added to BPCI Advanced)
  • Acute myocardial infarction
  • Back & neck except spinal fusion
  • Cardiac arrhythmia
  • Cardiac defibrillator
  • Cardiac valve
  • Cellulitis
  • Cervical spinal fusion
  • COPD, bronchitis, asthma
  • Combined anterior posterior spinal fusion
  • Congestive heart failure
  • Coronary artery bypass graft
  • Double joint replacement of the lower extremity
  • Fractures of the femur and hip or pelvis
  • Gastrointestinal hemorrhage
  • Gastrointestinal obstruction
  • Hip & femur procedures except major joint
  • Lower extremity/humerus procedure except hip, foot, femur
  • Major bowel procedure
  • Major joint replacement of the lower extremity
  • Major joint replacement of the upper extremity
  • Pacemaker
  • Percutaneous coronary intervention
  • Renal failure
  • Sepsis
  • Simple pneumonia and respiratory infections
  • Spinal fusion (non-cervical)
  • Stroke
  • Urinary tract infection

Outpatient Clinical Episodes

  • Percutaneous Coronary Intervention (PCI)
  • Cardiac Defibrillator
  • Back & Neck except Spinal Fusion

How will quality be measured?

CMS has selected seven quality measures for the BPCI Advanced Model

  1. All-cause Hospital Readmission Measure (NQF #1789) *Required for all episodes
  2. Advanced Care Plan (NQF #0326) *Required for all episodes
  3. Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF #0268) *Select episodes only
  4. Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF #1550) *Select episodes only
  5. Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF #2558) *Select episodes only
  6. Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (NQF #2881) *Select episodes only
  7. AHRQ Patient Safety Indicators (PSI 90) *Select episodes only

Which waivers are in place?

CMS has already provided details on some of the waivers that will be rolled over from older BPCI models, including rulings on the 3-Day SNF rule, Post-Discharge Home Visit Services, and Telehealth limitations.

While no ruling has been made public, it is anticipated that the fraud and abuse waivers from BPCI Classic will also extend to BPCI Advanced.

For more information on these waivers, please see the CMS handbook.

What are the keys to success under BPCI Advanced?

BPCI Advanced 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.

The most successful groups will be the ones who proactively redesign workflows, implement standardized care protocols regardless of a patient’s anticipated risk, and incorporate new technologies that allow more effective monitoring and coordination of patient populations.

It is crucial for participating group to assess their current operating procedures in order to determine any potential lapses in care coordination, which areas of post-acute care can be utilized more efficiently, and what opportunities exist to cultivate and sustain better patient engagement throughout the entire episode.

How can Claris Reflex help?

Claris Reflex is an effective means for practices and disconnected care teams to coordinate care across several different modalities as patients prepare for and recover from total joint replacements. Using the integrated Claris platform, members of the care team are able to efficiently track, coach and monitor their patients throughout the entire episode of care, while our proprietary CareDot system automatically triages patients based on associated risk levels so that workflow and resources can be redirected to those patients that need it the most.

The flexibility and mobility of the Claris Reflex telerehabilitation system allows case managers to follow patients as they move throughout the continuum of care, providing a safety net that will prevent patients from falling through the cracks as they discharge to and from different clinical settings. Clinicians are also able to receive and respond to actionable, customizable alerts via our mobile caregiver app, online caregiver console, or email, allowing them to react to adverse events in real-time and prevent costly readmissions.


CMS has made it clear with BPCI Advanced that the trend towards value-based models is here to stay. While enrolling in a bundled-payment program might not be the right decision for everyone, the No-Risk Offer included in this model provides a really attractive opportunity for groups that are trying their hand at bundled payments models for the first time. It is only a matter of time before participation in value-based care is no longer voluntary, and those groups with the more experience operating within the constraints of these models are setting themselves up to have the most success going forward.

For groups that are considering enrolling in the subsequent start dates, but may be confused on how bundled payments work, it is highly recommended that they seek out help from established conveners who have experience navigating the waters of BPCI. The right convener partner will work with the PGP or ACH to determine prospective target prices and potentials for gains and losses under BPCI Advanced, and can help groups make the right decision regarding future participation.

If you are an active or prospective BPCI Advanced participant and you are interested in finding out more about how Claris Reflex can help you reduce post-acute care costs and increase profits for your total joint replacement population, please make sure to schedule a short online demo and assessment today.

Download Claris Healthcare’s Guide to the CMS BPCI Toolkit

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