BPCI Advanced

What is BPCI Advanced?

The Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model is part of the continuing efforts by the Centers for Medicare & Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (Innovation Center) 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 participating in the Model on October 1, 2018. The second cohort started on January 1, 2020.  The third cohort of Participants started on January 1, 2024, and may participate until the BPCI Advanced Model period of performance ends on December 31, 2025.

Please subscribe to the BPCI Advanced Listserv for additional Model information and periodic updates.
 

Highlights

  • Often a patient who is admitted to the hospital (or receives an outpatient procedure) relies on doctors who don’t know them well nor have their full medical history. What’s more, the patient’s other doctors, including their primary care doctor, may not be looped in. This can create problems for the patient’s immediate treatment, as well as follow-up care and recovery.   
  • The BPCI Advanced Model aims to address these issues by having the BPCI Advanced Participant take responsibility for ensuring the patient’s entire health care team – including the providers from all health care settings – communicate and collaborate on quality and total cost of a patient’s care. The Participant facilitates coordination among the health care team, working to meet the patient’s full needs throughout the duration of the episode of care. 
  • The goal is to provide patients high-quality care, support a successful recovery and reduce the frequency and length of preventable hospital stays and emergency department use.

Quick Links - General Information Page

Model OverviewQuality MeasuresKey Stakeholders
Pricing MethodologyClinical EpisodesAdditional Information

Related Webpages:

Model Overview

CMS strives to foster an affordable, accessible healthcare system that puts patients first. To test a different approach to value-based care, CMS is moving away from individual fee-for-services payment towards a coordinated approach to the beneficiary’s needs. A provider in the BPCI Advanced Model becomes the accountable party in this total cost of care approach.

BPCI Advanced takes all the costs of care provided to a Medicare beneficiary during a Clinical Episode and “bundles” them into a single payment. The Clinical Episode includes the 90 days of care following discharge from an inpatient stay or when a outpatient procedure is completed. Care is provided and billed under standard fee-for-service payments. Twice a year, cost and quality are assessed. Depending on the aggregated number of claims paid by Medicare during the Clinical Episode relative to a Target Price, the Participant may receive additional payments from CMS, or might owe money to CMS. Payment models that have a “Total Cost of Care” approach can motivate health care providers to furnish services efficiently, to better coordinate care, and to improve quality of care.

BPCI-Advanced is defined by the following characteristics:

  • Voluntary Model
  • A single retrospective bundled payment and one risk track, with a 90-day Clinical Episode duration
  • 8 Clinical Episode Service Lines Groups with 29 Inpatient, 3 Outpatient and 2 multi-setting Clinical Episode Categories
  • 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, and final Target Prices will be constructed during Reconciliation

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.

Participants in the Model may not restrict beneficiary’s access to medically necessary care, nor the choice of providers or suppliers. Benefits will remain the same as if the provider or supplier providing the care was not participating in the Model. 

Who is a BPCI Advanced Beneficiary?

A patient enrolled in Medicare Parts A and B for the duration of the 90-day Clinical Episode. There are some exceptions. Participants in the Model may not restrict beneficiary’s access to medically necessary care, nor the choice of providers or suppliers. Benefits will remain the same as if the provider or supplier providing the care was not participating in the Model. 

Select anywhere on the map below to view the interactive version
Source: Centers for Medicare & Medicaid Services

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 review the Physician Fact Sheet (PDF) and Physician-Focused Materials section 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) in a Hospital Outpatient Department (HODP). 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 items and services that are provided during the Clinical Episode window, with some exclusions.

Starting 2023 the BPCI Advanced Model expanded the multi-setting Clinical Episodes Category of the Major Joint Replacement of the Upper Extremity to include outpatient Total Shoulder Arthroplasty procedure when triggered by HCPCS 23472. Therefore, since the start of Model Year 6, and continuing through Model Years 7 and 8, the model has 8 Clinical Episode Service Line Groups with 29 Inpatient, 3 Outpatient, and 2 multi-setting Clinical Episode Categories. 

Listing of Clinical Episode Service Line Groups Read more
 

Cardiac Care

  • Acute Myocardial Infarction (AMI)
  • Cardiac Arrhythmia
  • Congestive Heart Failure

Cardiac Procedures

  • Cardiac Defibrillator (Inpatient)
  • Cardiac Defibrillator (Outpatient)
  • Cardiac Valve
  • Coronary Artery Bypass Graft (CABG)
  • Endovascular Cardiac Valve Replacement
  • Pacemaker
  • Percutaneous Coronary Intervention (PCI - Inpatient)
  • Percutaneous Coronary Intervention (PCI - Outpatient)

Gastrointestinal Surgery

  • Bariatric surgery
  • Major bowel procedure

Gastrointestinal Care

  • Disorders of the Liver Except Malignancy, Cirrhosis, or Alcoholic Hepatitis
  • Gastrointestinal Hemorrhage
  • Gastrointestinal Obstruction
  • Inflammatory Bowel Disease

Neurological Care

  • Seizures
  • Stroke

Medical and Critical Care

  • Cellulitis
  • Chronic Obstructive Pulmonary Disease (COPD), Bronchitis, Asthma
  • Renal Failure
  • Sepsis
  • Simple Pneumonia and Respiratory Infections
  • Urinary Tract Infection

Spinal Procedures

  • Back and Neck Except Spinal Fusion (Inpatient)
  • Back and Neck Except Spinal Fusion (Outpatient)
  • Spinal Fusion

Orthopedics

  • 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) (Multi-setting Inpatient/Outpatient)
  • Major Joint Replacement of the Upper Extremity (MJRUE) (Multi-setting Inpatient/Outpatient)

Quality Measures

The CMS Innovation Center’s BPCI Advanced Model incentivizes 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.

The CMS Innovation Center provides 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 quality measure for Model Years 1-7, please visit the BPCI Advanced Quality Measures webpage.

Pricing Methodology and Payment

The BPCI Advanced Model uses a retrospective bundled payment approach. Specifically, under BPCI Advanced, CMS may make additional 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 Clinical Episode Exclusions, Clinical Episodes Construction, Reconciliation and Target Prices specifications for each model year. Please visit the Participants Resources web page to access these documents.

Evaluations

Latest Evaluation Reports

Prior Evaluation Reports

BPCI Advanced Participant Lists

Additional Information
Frequently Asked Questions (FAQs) by Topic

Physician-Focused Materials
BPCI Advanced Data Crosswalk

Information for Participants

Please visit the Participant Resources webpage for additional materials geared towards organizations or individuals actively participating in the Model.

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.

Where Health Care Innovation is Happening