On Oct. 1, 2018, the Centers for Medicare and Medicaid Innovation launched Bundled Payments for Care Improvement Advanced, a massive bundled payment model that reimburses participating providers with a single, lump-sum payment. BPCI Advanced is CMMI’s latest foray into the payment model and is an example of the agency’s iterative approach to payment reform, which mixes old design elements with new approaches. Additional details on the program can be found on the program’s official web page. For the sake of time, here are five important things to know about the program:


1. Participation is voluntary, though BPCI Advanced participants must bear risk. This means providers must meet quality and cost goals, or else make payments back to the Centers for Medicare & Medicaid Services in the form of penalties. CMMI’s intention is to foster accountability and drive care coordination and integration in organizations that have been slow to make the volume-to-value shift in care delivery.

2. Advanced integrated delivery networks are best-positioned to succeed. Here’s the catch: by being a voluntary program, BPCI Advanced is most likely to attract advanced IDNs that operate as well-integrated, self-contained systems. These networks are best positioned for success, as they can ease provider communication and care coordination across inpatient and post-acute care settings.

3. Participating physicians will qualify for payment incentives under the Medicare Access and CHIP Reauthorization Act’s Quality Payment Program. The QPP created a track for Advanced Alternative Payment Model participants and incentivizes participation in such models with a 5 percent lump-sum bonus payment. This additional incentive could be enough to attract physicians who previously did not explore, or otherwise would not have explored, AAPM participation.

4. BPCI Advanced will allow outpatient facilities to participate, albeit for only a trio of episodes. This means independent physician groups will be able to participate, and thus be required to shoulder risk. This will be an area to watch, as positive results could open the door for additional outpatient episodes in future models.

5. Orthopedic specialists will generate plenty of success stories, while results from other therapy areas will be mixed. Lower joint replacements are a particularly low-hanging fruit for organizations getting started with bundles. Hospitals may save hundreds of thousands of dollars, and in turn generate bonus payments, in LJR episodes by reducing institutional post-acute care utilization. Heart attack episodes, on the other hand, may be more difficult to predict and come with their own set of challenges, such as limiting complications and reducing readmissions and emergency room usage.


For more detailed analysis on the nation’s most advanced delivery networks, please see the Healthbase or Market Overview products.

Tyler Dinwiddie is a Senior Analyst for Market Access Insights. Follow Tyler on Twitter @TylerDinwiddDRG

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