April 26 2019 Amrita Sehgal, Charles Sauter, Josh Loehrer

What’s New for BPCI Advanced Model Year 3?

On April 24, 2019, CMS announced the enrollment period for the next cohort of BPCI Advanced participants. CMS will be accepting applications until June 24th, 2019, and Model Year 3 will begin January 1, 2020. Our BPCI-A experts have taken some time to review the changes and implications for program participants.


CMS will introduce five new clinical episodes, including Outpatient TKA and TAVR

CMS will include five new clinical episodes for BPCI-A Model Year 3: Outpatient TKA, Bariatric Surgery, Inflammatory Bowel Disease, Seizures, and TAVR.

The decision to add Outpatient TKA to the Major LEJR episode reflects the growing trend to perform more TKA procedures in the outpatient setting – often resulting in reduced costs and higher quality. In 2018, CMS removed TKA from the “inpatient-only” list, allowing TKA procedures to be reimbursed on an inpatient or outpatient basis. CMS included some initial guidance that indicates that Outpatient TKA might share a target price with the Inpatient Major Lower Extremity Joint Replacement episode but has not clarified the exact relationship between these two clinical episodes*.

The decision to include a TAVR episode is likely a direct result of the feedback CMS received during the previous Model Years. Previously, TAVR procedure costs were a significant barrier for participants to succeed in PCI episodes. While CMS has not clarified the exact relationship between the PCI and TAVR episodes, we anticipate that the creation of a separate TAVR episode should enable more participants to succeed in PCI episodes as well.

The other three new clinical episodes (Inflammatory Bowel Disease, Seizures, and Bariatric Surgery) are new to BPCI as they were also not included in the first BPCI program. CMS will provide additional details on the rules for these new episode types by the end of June 2019.

Participants may now select from a second set of Quality Measures

CMS has introduced a second set of quality measures for Participants to choose from in Model Year 3. The Alternate Quality Measures option includes measures derived from both registries and claims and are more specific to individual clinical episodes. Participants may choose metrics from either the Alternate Quality Measures or the Administrative Quality Measures, which were available in Model Years 1 and 2.

All Participants will be accountable for no more than five measures per Clinical Episode, whether they select the Administrative Quality Measures Set or the Alternate Quality Measures Set. CMS will provide additional details on the for these new quality measures by the end of June 2019.

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

In Cohort 1, CMS allowed participants to provisionally enroll in episodes with the option to drop out before March 1st. If they withdrew from any episodes, they were not financially accountable for any corresponding bonuses or penalties. CMS has suggested that 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.


Target Price Methodology

CMS did not release any details to suggest they are changing the target price methodology. CMS will continue to derive the target price based on hospital characteristics, patient case-mix, project trends among the hospital’s peer group, and historical episode spend over the baseline period. CMS will release a preliminary target price in September based on Participant’s historical case-mix and will set the final target price retrospectively at reconciliation.

For our current BPCI-A customers, Clarify provides target price and episode performance estimates as soon as CMS releases the data. These estimates are essential to understanding live financial performance in the program.

Impact of Quality on NPRA

Like Model Years 1 and 2, CMS will calculate a score for each quality measure at the episode level. These scores will be volume-weighted and scaled across all episodes to develop a composite quality score. This composite score can increase or decrease the total NPRA amount by up to 10%. Additional details on the Alternate Quality Measures and the composite score methodology will be released by the end of June 2019.

NPRA Shared Savings Cap

In March 2019, CMS announced they were considering removing the 50% cap on bonus and gainsharing payments to partner providers. In the recent announcement, CMS did not provide any additional details or clarifications on whether the cap would continue to exist in Model Year 3.


CMS will not release historical performance data until September 2019. That only leaves Participants a short time to make an educated decision for which episodes to participate in. Clarify’s proprietary data set includes the full set of Medicare part A, B, and D data, currently through Q3 2018. This data set enables Clarify to deliver actionable analytics on BPCI-A episodes without having to wait on the CMS data files. Clarify supports BPCI-A Participants in several ways, including:

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 to find out what else you need to know!

*CMS said: ”Outpatient TKA is a multi-setting Clinical Episode category. TKA procedures can trigger episodes in both inpatient and outpatient settings.”


UPDATE: 05/01/2019 

Be sure to watch our recorded webinar to learn more about the CMS announcement and how Clarify Health can support you in BPCI Advanced.

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