CMS Unveils BPCI–A

Deanna Stephenson in Managed Care

CMS has introduced the much anticipated BPCI-A (phase 2 of Bundled Payments for Care Improvement) to go live on 10/1/2018. For more information and expected timeline on this initiative, please see below.

Background on Bundling

Episode payment models provide a single bundled payment to health care providers for items and services furnished during an episode of care, while holding these health care providers accountable for the cost, quality, and patient outcomes during that episode. The Centers for Medicare and Medicaid Services (CMS) believes holding providers jointly accountable for resource management and total costs of care by bundling payment for multiple health care providers in multiple care-delivery settings with one lump sum for items and services furnished during a "clinical episode," improves coordination and creates incentives to deliver more efficient care. These bundled payment approaches are intended to encourage hospitals, physicians, post-acute care (PAC) providers, and other health care providers to better coordinate care, improve quality of care, and consider the financial implications of their treatment decisions. It can also help align health care provider incentives in pursuit of improved quality and reduced spending. An overview of the current BPCI effort is available here.

BPCI-A Key Provisions

The BPCI-A Applications (RFA) are due March 12, and applicants should be prepared to go live by October 1, 2018. A complete timeline for BPCI-A is available here.

As expected, the new model builds off the basic existing episodic structure of BPCI, but it also contains some important changes as well. First, there are no provider specific models (e.g., Model 2 - hospitals, Model 3 - PAC providers, and Model 4-physician groups). All participants will operate within the same model. Also, terminology for organizing entities has changed. The terms "Awardee Conveners," which are risk-bearing, and "Facilitator Conveners," which are non-risk-bearing, have been eliminated. Under BPCI-A, "conveners" are defined as participants that pull together downstream providers (e.g., episode initiators which must be acute care hospitals [ACH] or physician group practices [PGP]), facilitate coordination among downstream entities and bears and apportions risk. Non-convener participants are participants that have similar responsibilities to convener participants but bears risk only for themselves, not on behalf of downstream episode initiators.

While ACHs and PGPs only may be episode initiators, there appear to be no barriers to PAC providers applying to be convener or non-convener participants. Rather, the RFA makes clear that applicants will be selected for participation in BPCI-A (click here to view the application) based upon CMMI criteria. And while CMS spells out its applicant approval guidelines, there is no set application scoring method identified. A review of the guidelines makes clear that CMS is seeking experienced and motivated risk takers with an ability to redesign and coordinate care rather than designating specific entities. While the criteria for serving as Participants may be difficult for some SNF professionals, application could be an important opportunity. AHCA is in the process of verifying this potential opportunity.

Both convener and non-convener participants may enter into agreements with individual downstream physicians and non-physician practitioners, referred to as Participating Practitioners. They also may enter into financial arrangements with entities that qualify as "Net Payment Reconciliation Amount (NPRA) Sharing Partners," which includes PAC providers. SNFs might also have the opportunity to form PAC Care Management arrangements with conveners and non-conveners. Again, AHCA is verifying the feasibility of this potential opportunity.

Additionally, SNF outreach and partnerships with physicians will be critical. Participating in BPCI-A makes physicians eligible for 5 percent bonus payments on their professional fees if certain performance metrics are hit under the new physician payment structure. At this point, AHCA expects physician interest to be high.

The new voluntary program has up to 32 different clinical episodes, including three episodes that would be triggered by outpatient care in addition to 29 episodes triggered by inpatient hospitalization (as in the current program). BPCI-A will now directly incorporate up to seven quality metrics into the target price reconciliation process, similar to how quality is incorporated in the Comprehensive Joint Replacement Model. Two of the seven quality measures, all-cause re-hospitalization and advance care planning, will be applied across the board, while the others are applied to specific clinical episodes. CMS may add or refine quality measures over time and they are expecting applicants to have a solid game plan on monitoring quality.

Finally for SNFs contracting with conveners, under the Three-Day Stay Waiver, a Qualified SNF is a SNF that: (1) has an overall rating of three or more stars in the Nursing Home Five-Star Quality Rating System for SNFs on the CMS Nursing Home Compare Website for at least seven of the 12 preceding months; and (2) is identified on the list of SNFs eligible to be Qualified SNFs posted on the CMS website, as determined by CMS based on the most recent rolling 12 months of SNF star rating data available that includes the date of the beneficiary's admission to the SNF. CMS will post the list of SNFs that CMS determines are eligible to be Qualified SNFs on a quarterly basis here.

On January 31, from 3-4PM Eastern, AHCA will host a webinar for AHCA members on SNF opportunities and options. Information on how to access the webinar will be shared shortly. Please feel free to contact me with any questions, suggestions, or concerns.


Michael W. Cheek
Senior Vice President
Reimbursement Policy


Deanna Stephenson
Director, Managed Programs
518-462-4800 x16