April 18 2019 Amrita Sehgal, Charles Sauter, Josh Loehrer

Getting ahead of CMS’ BPCI Advanced Announcement

Healthcare providers are anxiously awaiting the CMS enrollment announcement for the next BPCI Advanced cohort. What will change? And what will these changes mean for you? In anticipation of the announcement, our expert analysts have provided some initial answers based on the information CMS has already made available.


CMS’s Bundled Payments for Care Improvement – Advanced program is the next iteration of its voluntary bundled payment program, BPCI. On October 1, 2018, about 1,500 participants started the BPCI Advanced program. After the March 2019 withdrawal deadline, approximately 1,300 participants remain in Cohort 1. Cohort 2 will start the program on January 1, 2020. Both BPCI-A cohorts will run through December 31, 2023.

For a full rundown on BPCI-A, catch up on our BPCI Advanced Fast Facts post.


Here is what we’ve heard thus far:

1. CMS will introduce a new outpatient total knee arthroplasty (TKA) episode

In 2018, CMS removed TKA from the “inpatient-only” list, allowing reimbursement for TKA procedures on an inpatient or outpatient basis. To follow suit in episode payments, CMS has announced that it will add an outpatient TKA episode in this next wave of BPCI Advanced. This move reflects the growing trend to perform more TKA procedures in the outpatient setting – often resulting in reduced costs and higher quality.

We expect inpatient TKA procedures to remain in the Major LEJR episode. Outpatient TKA will likely be its own episode with a separate target price. However, considering the low volume of outpatient TKA procedures, it is unclear how robust CMS’ target price model will be since historical benchmarking will be difficult.

The introduction of this episode will increase the overall TKA volume in BPCI Advanced. However, before making any final enrollment decisions, program participants should evaluate how CMS plans to determine the target price and the implications on their potential bonus/penalty for the episode type.

2. CMS removed the 50% cap on NPRA shared payments and partner distribution payments

Previously, CMS imposed a 50% cap on bonus and gainsharing payments that the “owner” of the BPCI-A bundle could make to partner providers. Eliminating this cap will improve financial upside for many downstream providers participating in BPCI-A. For example, hospital Episode Initiators that are non-convened in BPCI-A and that have gainsharing agreements in place with partner physician group practices (PGPs) now have more flexibility in the amount of gainsharing they can provide.

The removal of the 50% cap will spark a renewed interest in understanding the performance of current and potential provider partners. Precise analytical tools can help illuminate the performance of high-value providers to facilitate the decision-making around these gainsharing payments.

3. This enrollment period will likely be the last opportunity to enter BPCI-A

CMS has suggested that this application period will be the final opportunity for providers to enroll in BPCI Advanced. Voluntary programs like BPCI and BPCI-A have provided an opportunity for providers to gain experience in bundled payment models and to pilot strategies for success before future programs are mandated at a larger scale.

Providers that are participating in the BPCI-A program have started to redesign the delivery of care to patients and rethink the way that they engage with patients throughout the journey. This prior experience in voluntary bundles is critical as we already see mandatory CMS bundles on the horizon in Radiology, Oncology, and Cardiology.

4. There will not be a “try before you buy” period this time

In Cohort 1 of BPCI-A, CMS allowed participants to provisionally enroll in episodes with the option to drop out prior to March 1st, 2019. If they withdrew from any episodes, participants were not financially accountable for any corresponding bonuses or penalties.

CMS has suggested that this was a one-time opportunity for engaging in the BPCI-A program. For Cohort 2, participants who withdraw from any episode will likely be held responsible for any bonus and penalties incurred in the program thus far.

This means Cohort 2 participants need to be very confident in their episode enrollment decisions. The critical component to making informed episode selections is access to robust and timely data that can be used to predict future performance.


The BPCI-A program will continue to offer hospitals and physician groups an exciting opportunity to redesign care delivery, improve the value of patient care, and earn a financial upside through bonus payments. CMS will make some adjustments to the program rules for this next application period, and officials have provided some interesting previews into how the program rules will likely change. Stay tuned as CMS makes the official announcement to get an updated perspective on what the new rules could mean for you.


Complete Diagnostic Assessment: Episode recommendations and scenario analysis
Performance and Change Management: Insights on program performance and areas for improvement
Patient Identification and Stratification: Identification of bundle patient and risk stratification upon hospital admission

Learn more about our BPCI solution and look out for more Clarify BPCI-A content after the CMS announcement to find out what else you need to know!

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