Bundled Payments for Care Improvement (BPCI) Advanced is a voluntary model developed by the Centers for Medicare and Medicaid Services (CMS) to test bundled payments for 90-day clinical episodes of care related to 32 conditions or procedures. The model began October 1, 2018, and will run through December 31, 2023. For those who missed joining this first cohort, a second application opportunity opens in spring 2019 for a model period that begins January 2020. BPCI Advanced qualifies as an Advanced APM under the Medicare Quality Payment Program (QPP). Questions regarding BPCI Advanced should be sent to firstname.lastname@example.org.
APTA offers these 4 steps to follow as you consider joining a BPCI Advanced model.
Step 1: Understand BPCI Advanced
BPCI Advanced is designed to address all Medicare fee-for-service beneficiaries (Parts A and B) who receive care during one of the listed clinical episodes within the model. An episode begins at the start of either an inpatient admission to an acute care hospital (ACH), called the anchor stay, or an outpatient procedure, called the anchor procedure. An anchor stay is identified by a Medicare Severity-Diagnosis Related Group (MS-DRG) for a condition, and a clinical episode is triggered by submission of a claim identified by a MS-DRG. An anchor procedure is identified by Healthcare Common Procedure Coding System (HCPCS) code for an outpatient procedure, and a clinical episode is triggered by submission of a claim identified by a HCPCS code. The clinical episode ends 90 days after the end of the anchor stay or the anchor procedure.
Entities that want to organize and oversee a model must enter into a BPCI Advanced Model Participation Agreement with CMS and are required to take on downside financial risk from the outset of the model's performance period.
These organizers are considered either conveners or nonconveners. Conveners can be any of the following: Medicare-enrolled providers or suppliers; other types of entities that are not enrolled in Medicare; acute care hospitals (ACHs); or physician group practices (PGPs). They bring together 1 or more downstream entities referred to as episode initiators (EIs) as they kick off a particular clinical episode. EIs must be either ACHs or PGPs, and if the convener is an ACH or PGP itself, then it also can be an EI. Conveners facilitate coordination among model participants, and they bear and apportion financial risks on behalf of the downstream entities. Nonconveners—which are either ACHs or PGPs—are the model's EIs, and they bear financial risk only for themselves.
In addition to the EI entities, both conveners and nonconveners may bring in downstream providers to furnish care and participate in other activities within the model, such as care redesign, quality measure reporting, and use of certified EHR technology (CEHRT). These downstream providers, called participating practitioners, typically are physician and nonphysician providers, including physical therapists. Whether or not they share in the rewards and risks of the model, participating providers continue to be paid separately by Medicare for their services.
To be eligible for the rewards and shared savings achieved by the model, participating practitioners must meet certain requirements and enter into formal arrangements with the convener or nonconvener as "net payment reconciliation amounts (NPRA) sharing partners." This means they agree to share the reward or risk as apportioned by the convener or nonconvener. Conveners or nonconveners also can make formal arrangements with participating practitioners who are not NPRA partners, but the practitioners will not share in the reward or risk, and the advantages of being in the model are limited.
Examples of BPCI arrangements:
- Company X contracts with CMS as a convener. Company X contracts with Hospital A, Hospital B, and Physician Group C, to initiate clinical episodes under BPCI Advanced. Hospitals A and B each will initiate the "major joint replacement of lower extremity" clinical episode under the model; Physician Group C will initiate the "back and neck except spinal infusion" clinical episode. Company X also enters into an agreement with Amanda's PT Practice to furnish physical therapy services during these clinical episodes under the model. As a convener, Company X bears the risk for Hospital A, Hospital B, and Physician Group C in the model.
- Company X: Convener
- Hospital A: EI
- Hospital: B: EI
- Physician Group C: EI
- Amanda's PT Practice: Participating practitioner
- Hospital A contracts with CMS as a nonconvener to serve as an EI, directly providing services for 2 types of clinical episodes: "fractures of the femur and hip or pelvis" and "hip and femur procedures except major joint." Hospital A enters into an agreement with Smith's PT Practice and John's PT Practice to furnish services during these clinical episodes under the model. As a nonconvener, Hospital A bears risk for itself.
- Hospital A: Nonconvener/EI
- Smith's PT Practice: Participating practitioner
- John's PT Practice: Participating practitioner
- Physician Group A contracts with CMS as a nonconvener to initiate 1 type of clinical episode: "back and neck except spinal infusion." Physician Group A enters into an agreement with Kelly's PT Practice to furnish care under this model. The agreement outlines how Physician Group A and Kelly's PT Practice will share money received by CMS or repay amounts owed to CMS by Physician Group A, based on Physician Group A's level of success in reducing costs and increasing quality.
- Physician Group A: Nonconvener/EI
- Kelly's PT Practice: NPRA sharing partner
Step 2: Determine if BPCI Advanced Is Right for Your Practice
If your practice engages in care redesign, participates in quality measure reporting, and uses CEHRT, then you should consider the following before deciding whether or not to be a participating practitioner, and possibly an NPRA sharing partner, in a BPCI Advanced model:
- Identify the clinical episodes from the CMS list that are most applicable to your practice area.
- Identify EIs in your geographic area:
- Do you already have a relationship with an EI(s)?
- What clinical episodes have they selected?
- Are they applicable to your practice?
- Use these CMS resources to help answer the questions:
If you determine that you or your practice satisfies the definition of a participating practitioner, and you would like to pursue an NPRA sharing partner arrangement, you must determine if you engage in qualifying activities and if you are willing to take on the needed risk.
Examples of qualifying activities related to the overall care of BPCI Advanced beneficiaries during a clinical episode include furnishing direct patient care pursuant to a care redesign plan, reporting on quality measures, using CEHRT in a way that would satisfy the BPCI Advanced participation agreement, and attesting to a minimum of 4 Merit-based Incentive Payment System (MIPS) improvement activities. (CMS may specify other activities as well.) Once you've determined that you meet the eligibility criteria, you need to assess your willingness and ability as an NPRA sharing partner to be held accountable for the model's quality and cost of care. This could mean owing CMS repayment amounts if the model doesn't meet its goals and the financial arrangement calls for you to absorb some of the cost.
Knowing the provisions of the financial arrangement will be important to making your decision.
The financial arrangement will describe the proportion of payments to be shared with NPRA sharing partners, how the payment amounts will be calculated, when and how often payments will be issued, and how repayments to CMS will be handled if the model doesn't meet the stated criteria for success.
If you are willing to take on risk, there is significant opportunity for reward. Not only can you share in some of the model's savings if it's successful, but BPCI Advanced qualifies as an Advanced APM within the CMS Quality Payment Program. If you are required to participate in QPP—as many private practice PTs now are, successfully being part of a BPCI Advanced model can exempt you from the MIPS.
Learn more about eligibility as a Qualifying Participant in an Advanced APM.
Step 3: Pursue a Financial Arrangement With a Participant
If you or your practice have considered all of the above and believe you could be a valuable partner in a BPCI model in your area, it's time to pursue a financial arrangement with a convener or nonconvener. Be prepared to describe the following to market yourself:
- How your actions can reduce episode spending
- How your participation will improve care quality
- The evidence-based guidelines you would use that are applicable to the episode(s) population
- Tools you have to assess the patient's needs, preferences, and values
- Your care transition and coordination tools and procedures, such as EHRs, registries, standard protocols
- Measures you will use to assess quality performance, patient function, patient experience, care coordination, and other data points
In addition, present the participant(s) with detailed plans on how you, as an NPRA sharing partner, can help the model achieve improved care outcomes, including:
- Aspects of care that will be redesigned and plans for improving care quality
- Capacity and readiness to improve care quality
- Plans to assess beneficiary, caregiver, and/or family experience of care
This APM Contracting Checklist (.pdf) includes other aspects to consider in your marketing efforts.
Step 4: Stay Up-to-Date on Clinical Practice Resources
BPCI Advanced includes 7 quality measures. The first 2 below—All-cause Hospital Readmission Measure and Advance Care Plan—are required for all clinical episodes. The other 5 apply only to selected clinical episodes:
- All-cause Hospital Readmission Measure (NQF #1789)
- Advanced Care Plan (NQF #0326)
- Perioperative Care: Selection of Prophylactic Antibiotic: First or Second Generation Cephalosporin (NQF #0268)
- Hospital-Level Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) (NQF #1550)
- Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Coronary Artery Bypass Graft Surgery (NQF #2558)
- Excess Days in Acute Care after Hospitalization for Acute Myocardial Infarction (NQF #2881)
- CMS Patient Safety Indicators (PSI 90)
Delivering consistent evidence-based care, tracking your outcomes, and educating potential collaborating providers are keys to success in the BPCI Advanced model and in most other new payment models moving forward. The following resources can help in these activities:
- Guide to Physical Therapist Practice
The Guide to Physical Therapist Practice may be helpful in educating others on the role of physical therapy in collaborative care teams, and showing how physical therapist interventions may result not only in more efficient and effective care but also in more appropriate use of other members of the primary care team.
APTA's PTNow clinical resources for physical therapists, physical therapist assistants, and students, including clinical summaries, clinical practice guidelines, Cochrane reviews, Rehabilitation Reference Center, and more.
- Physical Therapy's Role in Reducing Hospital Readmission
Physical therapists have expertise in providing recommendations for the most appropriate level of postacute care following surgery. You can make the case for being included in the health care team prior to and during care transitions to help in reducing hospital readmissions.
- Using Outcome Measures
It is important to measure and report patient care outcomes within the relevant components of function to show best clinical practice to patients, providers, and payers.
- Providing Services Via Telehealth
Review APTA's guidelines on providing physical therapy using telehealth as well as issues to be aware of before
- Community-Based Programs
To extend the benefits of your treatment and help your patients improve or maintain their mobility and independence, here are examples of community programs that emphasize physical activity and self-management to decrease the chance of readmission.