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BPCIA: 4 fast facts for a successful Model Year 7 kickoff

Doctor smiling, excited for BPCIA Model Year 7.

Participation in Model Year 7 launched on Jan. 1, 2024, with the first few months being a critical time for providers. New Bundled Payments for Care Improvement Advanced Model (BPCIA) participants got their footing, and continuing participants were able to change their clinical episode service line groups for the first time since 2020. 

If you’re a provider participating in this model, read on for a BPCIA refresher and four fast facts for starting MY7 right. We’ll also cover core analytics activities to support your clinical and operational success. 

 4 Fast facts on BPCIA Model Year 7 

1.   Focus on clinical episodes and episode volume 

Before MY7 began, providers used historic baseline data provided by CMS to evaluate which CESLGs they would go at risk for, ensuring there would be sufficient episode volume. Large episode volume (100 episodes/year or more) reduces random variation and helps protect providers from financial risk associated with outlier Medicare episode spend.   

During the model year, it is important that providers use their internal data systems to monitor which patients will trigger BPCIA episodes and account for specific exclusion criteria to the best of their ability. This is important for several reasons: 

  • Providers must provide these patients with CMS’s beneficiary notification letter to inform them of their inclusion in the BPCIA Model, their right to access medically necessary covered services and their right to choose any provider or supplier.  

  • Providers will need to closely monitor and potentially engage with these patients across the care continuum in the 90 days post-discharge.   

  • Providers will be accountable for several quality measures related to utilization and outcomes for these patients.   

2.   Monitor utilization and expected care patterns  

Providers should carefully examine their episodes by patient risk profile and ask these three key questions, including: 

  • Does each episode have a well-designed care plan? 

  • Have patients received the care plan? 

  • Are patients able and willing to follow the care plan? 

Providers should evaluate which types of post-acute care are being utilized and if it is appropriate for the patient. They should also assess which providers a patient is receiving subsequent care from (and their CMS star rating), the length of stay and the occurrence of direct readmissions.  

The type of post-acute care and length of stay have a direct impact on Medicare episode spend. In addition, some readmissions, especially those for ambulatory care sensitive conditions, may have been preventable and can indicate where improvements in care coordination must be made.  

3.   Re-confirm strategy strength and clinical buy-in 

Predictable utilization and care patterns can generate better outcomes throughout the year and beyond BPCIA. Achieving long-term practice transformation is one of the many benefits of bundled payments and other APMs.  

Keeping clinicians, staff and program champions engaged and informed of ongoing performance is critical to these efforts, especially when episode targets and intervention approaches change. While CESLGs are already locked in, key insights used for BPCIA episode selection will remain valuable throughout the model year. 

4.  Track BPCIA initiatives and their impact 

The first few months of the new BPCIA model year are ideal for revisiting Key Performance Indicators. For practice transformation, providers need to know if their efforts are working for all patients equitably. If not, they must be able to pivot in ways that still meet BPCIA requirements. 

KPIs that apply to multiple initiatives have high value, e.g., the CMS Hospital Readmissions Reduction Program. They also address heart attack, heart failure, bypass surgery and joint replacement. Such intersections can break down practice silos, expand value-based care and help providers achieve the industry’s now Quintuple Aim: improving population health, patient experience and healthcare costs while focusing on health equity and workforce satisfaction. 


Quick overview of BPCIA MY7 

What is BPCIA MY7? 

BPCIA is a voluntary program that tests whether linking payment across episodes of care and care settings can lower costs and impact quality. BPCIA MY7 offers providers financial incentives if they deliver quality care below target prices. The model also helps them transform and standardize patient care. 

How has BPCIA Changed?  

MY7 includes 207 participants, 99 of which are returning and 108 new. Of the 207, only 46 are Convenors, organizations that bear risk for participating providers. They’re also known as Downstream Episode Initiators. 

Episode Initiators include acute care hospitals and physician group practices. MY7 includes 123 acute care hospitals and 124 physician group practice participants, per the CMS BPCIA model summary. 

MY7 also includes 34 Clinical Episode Categories clustered into eight Clinical Episode Service Line Groups. These CESLGs, ranked in order of provider choice, are: 

1.    cardiac care; 

2.    medical and critical care; 

3.    orthopedics; 

4.    gastrointestinal care; 

5.    neurological care; 

6.    gastrointestinal surgery; 

7.    spinal procedures; and 

8.    cardiac procedures. 

CMS published lists of all BPCIA participants and Episode Initiators/CESLGs on its BPCIA website. The higher-ranking groups suggest more providers believe they can control Medicare episode spend in these areas.  


A strong start can lead to better outcomes 

A successful kickoff to the BPCA model year can lead to better outcomes, cost control and patient experience. Whether you are a new or returning provider to MY7, DataGen can help you reach your goals and thrive in BPCIA. Contact us today for a free consultation. 

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