BPCI Advanced Model Extension for Two Years (2024-2025) and Changes for 2023

The Bundled Payments for Care Improvement Advanced (BPCI Advanced) Model will be extended for two years, the Centers for Medicare & Medicaid Services (CMS) announced this week. The BPCI Advanced Model, which launched on October 1, 2018, was set to end on December 31, 2023, and will now conclude on December 31, 2025.

BPCI Advanced is an Advanced Alternative Payment Model (Advanced APM) under the Quality Payment Program (QPP), and tests whether linking payments for an episode of care will incentivize health-care providers to invest in practice innovation and care redesign to improve care coordination and reduce expenditures while maintaining or improving the quality of care for Medicare beneficiaries.

As of December 31, 2021, more than 1.2 million Medicare beneficiaries have received care from participants in the BPCI Advanced Model, and more than 1,800 Acute Care Hospitals (ACHs) in coordination with 69,867 physicians have engaged in care redesign activities because of participation in the BPCI Advanced Model.

This two-year extension will include a new application opportunity. CMS plans to announce a Request for Applications (RFA) in early 2023 for Medicare-enrolled providers and suppliers and Medicare Accountable Care Organizations (ACOs) to participate in the Model’s two-year extension (2024-2025). To be eligible for participation in the extension, convener applicants must be Medicare-enrolled entities or ACOs. Existing convener participants will be permitted to remain in the BPCI Advanced Model during the extension years, and ACHs and physician group practices (PGPs) may join existing convener participants as downstream episode initiators (EIs) during this period. Those interested in applying as non-convener applicants will need to either be an ACH or a PGP.

Both convener participants and non-convener participants active during Model Year 6 (2023) will have the opportunity to continue to participate in the model by signing an Amended and Restated Participation Agreement for Model Year 7 (2024).

Additionally, EIs (ACHs or PGPs) that previously participated in the model, but are no longer active, will also have the opportunity to apply for Model Year 7 (2024). More details will be made available on participating in the extension in the coming months.

Also, the following changes will be implemented to improve the pricing methodology and keep providers and suppliers engaged in value-based care through the BPCI Advanced Model in Model Year 6 (2023):

• Reducing the CMS discount for medical clinical episodes from 3% to 2%.
• Reducing the Peer Group Trend Factor Adjustment cap for all clinical episodes from 10% to 5%.
• Making major joint replacement of the upper extremity a multi-setting clinical episode category by including outpatient total shoulder arthroplasty procedures (triggered by Healthcare Common Procedure Coding System 23472) in the model. CMS will also include a trauma/fracture flag and major joint replacement of the upper extremity procedure group flag along with their interactions in the risk adjustment for this clinical episode.
• Holding participants accountable for all clinical episodes in which the beneficiary has a COVID-19 diagnosis during the clinical episode.

The two-year extension will allow CMS to test and evaluate these changes for Model Year 6 for three years total.

The CMS Innovation Center is building on these lessons, challenges, and barriers to test models that provide tools, support, and financial incentives that will enable greater integration of primary and specialty care to meet the needs of an increasingly complex population of beneficiaries. Integrated and coordinated care for beneficiaries is an essential feature of a health system that achieves equitable outcomes through accountable, high-quality, affordable, person-centered care.

Bundled payments for specialty care complement care transformation in other initiatives, and strategic implementation of episode-based models can help fill the geographic and demographic gaps where accountable entities have yet to extend their reach and can keep moving the health system toward accountability for quality and spending outcomes.

The CMS Innovation Center looks forward to providing more details on its specialty care strategy soon and encourages those interested to attend the Health Care Payment Learning & Action Network (LAN) Summit November 9-10, 2022.

For more details on this announcement, please review the Model Extension and Changes for Model Year 6 (2023) Fact Sheet.

A complete BPCI Advanced Model Overview Fact Sheet for Model Year 6 (2023) is available here.

For more information, please visit this webpage.

You can also contact the BPCI Advanced Model team at BPCIAdvanced@cms.hhs.gov.