On Oct. 1, 2018, the Centers for Medicare & Medicaid Services (CMS) announced its newest value-based purchasing program: Bundled Payments for Care Improvement Advanced (BPCI A). Different from previous iterations of bundled payments, this version is focused on acute care and primary care providers as episode initiators (EIs).

There are many technical aspects to this program that can be fully digested by visiting CMS.gov. The purpose of this article is to provide the basic underpinnings of the program that will directly impact post-acute care (PAC) providers and inform their response when (not if) they are approached by a local acute care provider participating in BPCI A.

What is BPCI A?

BPCI A, like its predecessors, is driven by the final discharge diagnosis of the patient receiving inpatient or outpatient service.

BPCI A makes available to EIs the choice of 29 inpatient clinical episodes (hospital stays) and three outpatient clinical episodes (procedures). Since the three outpatient clinical episodes—Percutaneous Coronary Intervention, Cardiac Defibrillator, and Back and Neck (except spinal fusion)—are somewhat limited and specialized, this article will not address them.

BPCI A most notably is built around an episode of care that runs a total of 90 days and begins at the point that the patient is discharged from the EI acute care hospital. PAC providers need to be aware of the following issues.

Confirmation that SNF Admission is part of BPCI A

This key issue is complicated because the determination if a patient is in fact ascribed to BPCI A is driven by the final discharge diagnosis assigned by the coders working for the hospital. Since this can take up to 14 days post hospital discharge to be completed—effectively not known until the patient is likely discharged from the skilled nursing facility (SNF) to home, hospitals will rely on concurrent coding done by hospital staff during the patient’s acute stay or by a program that reviews all pertinent medical facts and predicts what the discharge diagnosis will be.

Regardless of how the hospital makes a conditional determination, SNFs that receive communication from the discharging hospital that a patient may be a part of BPCI A need to find a way to receive confirmation that the final discharge diagnosis places the patient in the BPCI A program. This will help the SNF know better how to strategically manage that patient’s stay and post-discharge arrangements.

Hospitals participating in BPCI A will have a strong incentive to direct potential BPCI A patients to facilities that are a part of their network. This should not in any way impede non-network SNFs from continuing to market their facilities to potential patients. Word of mouth, previous experience, and geographic location will continue to be strong determinants in where traditional Medicare patients seek SNF care.

SNF Length of Stay

Since the SNF stay will have a direct and relatively significant impact on the 90-day spend, hospitals will have a keen interest in how long the patient stays in the SNF. This interest will vary from hospital to hospital as well as the sophistication of determining appropriate length of stay to be communicated to the SNF.

Ultimately, the length of stay (LOS) is a decision made by the SNF through the use of proper internal utilization review protocols. Succumbing to implied or overt pressure from the hospital to reduce LOS may buy the hospital’s short-term happiness, but in the long run, it may lead to post-SNF stay negative outcomes.

Home Care Hand-off

When the SNF is ready to discharge the patient back to their home in the community, a critical element will be the choice of and execution by the patient’s chosen home care provider. In the absence of a choice by the patient, due consideration should be given to using home care providers affiliated or endorsed by the acute care hospital. If there is a downstream negative outcome such as a readmission from the community, the SNF will be better positioned to defend its actions and any involvement or failure by the home health partner.

In BPCI A, the primary care physician (PCP) will bear much responsibility for monitoring and managing the care of community-dwelling patients during the bulk of the 90-day bundle episode. Therefore, the SNF must make certain that the patient’s PCP is aware of what has transpired during the patient’s SNF stay and plans for a transition home. Additionally, the SNF should help coordinate a post-discharge office visit with the patient’s PCP.


For years, SNFs have developed systems for avoiding 30-day readmissions to the hospital while the patient is being cared for in the SNF. They are all too aware of the implications this has on them and their acute care partners.

In BPCI A, the issue of readmissions is expanded by making the risk period a full 90 days after hospital discharge. In order for a proportionate discussion and analysis of any 90-day readmissions, SNFs should consider stratifying the readmissions that occur post discharge from the SNF to the community in the following manner:

 Readmission TimeFrame from SNF Discharge Date Responsible Party
0-2 days SNF/Home Care Provider
2 days-end of Home Care Coverage Home Care Provider
End of Home Care Coverage-End of 90-day Episode Episode​ Home Care Provider/Hospital Episode  Initiator

Tracking patients in a very concise way will enable the SNF to ensure that responsibility for readmissions is assigned to the party that is most responsible.

Reward ​versus Risk

Hospitals are wading into this voluntary episode payment model with due caution. The reasons are many, and the time frame for them to make a final decision about a five-year commitment to remain in the program is short—March 31, 2019.

As hospitals move into the full-on five-year time commitment, their attention will undoubtedly turn to risk/reward sharing arrangements with post-acute partners. At this point, SNF providers will need to truly weigh the risks and rewards of any such arrangements.

Most significantly, BPCI A is structured with a 90-day episode with more than two-thirds of this time span occurring outside of the control/observation of the SNF. The list of social determinants that make control of the health outcomes during this 15- to 90-day time interval problematic is endless and includes:

  • A disproportionally aged population;
  • Comorbid conditions;
  • Logistical challenges for gaining access to fresh food/medicine/doctors;
  • Lack of social/familial supports;
  • Financial limitations impacting ability to pay for necessary medications/treatments; and
  • Lifestyle choices that either created or exacerbate the existing health condition(s).

In the author’s opinion, CMS opted for the 90-day episode bundle length to transfer the risk inherent in this population to private entities—in this case, hospitals. SNFs need to be clear-eyed about the upside reward and downside risk of entering into any risk/reward sharing arrangements in light of this extraordinary time span.

Kevin McMahon is a licensed nursing home administrator and can be reached at indomit@aol.com.