Bundled Payment Programs and Changes in Practice Patterns and Episode Spending in Major Gastrointestinal Surgery.

Percutaneous coronary intervention (PCI) is a common and expensive procedure that has become a target for bundled payment initiatives. We described the magnitude and determinants of variation in 90-day PCI episode payments across a diverse array of patients and hospitals. We linked clinical registry data from PCIs performed at 33 Michigan hospitals to 90-day episodes of care constructed using Medicare fee-for-service and commercial insurance claims from January 2012 to October 2016. Payments were price standardized and risk adjusted using clinical and administrative variables in an observed-over-expected framework. Hospitals were stratified into quartiles based on average episode payments. Payment components between the highest and the lowest quartiles were compared with identified drivers of variation (ie, index hospitalization/procedure, readmissions, postacute care, and professional fees). Among 40 925 90-day PCI episodes, the average risk-adjusted 90-day episode payment by hospital ranged between $22 154 and $27 205 with a median of $24 696 (interquartile range, $24 190-$25 643). Hospitals in the lowest and the highest quartiles had average episode payments of $23 744 and $26 504, respectively (difference, $2760). Readmission payments were the primary driver of this variation (46.2%), followed by postacute care (22.6%). Readmissions remained the primary driver of variation in key subgroups, including inpatient and outpatient PCI, as well as PCI for acute myocardial infarction and nonacute myocardial infarction indications. Substantial hospital-level variation exists in 90-day PCI episode payments. Over half the variation between high- and low-payment hospitals was related to care after the index procedure, primarily because of readmissions and postacute care. Hospitals and policymakers should consider targeting these components when developing initiatives to reduce PCI-related spending.

Coronary artery bypass grafting (CABG) is scheduled to become a mandatory Medicare bundled payment program in January 2018. A contemporary understanding of 90-day CABG episode payments and their drivers is necessary to inform health policy, hospital strategy, and clinical quality improvement activities. Furthermore, insight into current CABG payments and their variation is important for understanding the potential effects of bundled payment models in cardiac care. To examine CABG payment variation and its drivers. This retrospective cohort study used Medicare and private payer claims to identify patients who underwent nonemergent CABG surgery from January 1, 2012, through October 31, 2015. Ninety-day price-standardized, risk-adjusted, total episode payments were calculated for each patient, and hospitals were divided into quartiles based on the mean total episode payments of their patients. Payments were then subdivided into 4 components (index hospitalization, professional, postacute care, and readmission payments) and compared across hospital quartiles. Seventy-six hospitals in Michigan representing a diverse set of geographies and practice environments were included. Ninety-day CABG episode payments. A total of 5910 patients undergoing nonemergent CABG surgery were identified at 33 of the 76 hospitals; of these, 4344 (73.5%) were men and mean (SD) age was 68.0 (9.3) years. At the patient level, risk-adjusted, 90-day total episode payments for CABG varied from $11 723 to $356 850. At the hospital level, the highest payment quartile of hospitals had a mean total episode payment of $54 399 compared with $45 487 for the lowest payment quartile (16.4% difference, P < .001). The highest payment quartile hospitals compared with the lowest payment quartile hospitals had 14.6% higher index hospitalization payments ($34 992 vs $30 531, P < .001), 33.9% higher professional payments ($8060 vs $6021, P < .001), 29.6% higher postacute care payments ($7663 vs $5912, P < .001), and 35.1% higher readmission payments ($3576 vs $2646, P = .06). The drivers of this variation are diagnosis related group distribution, increased inpatient evaluation and management services, higher utilization of inpatient rehabilitation, and patients with multiple readmissions. Wide variation exists in 90-day CABG episode payments for Medicare and private payer patients in Michigan. Hospitals and clinicians entering bundled payment programs for CABG should work to understand local sources of variation, with a focus on patients with multiple readmissions, inpatient evaluation and management services, and postdischarge outpatient rehabilitation care.

Much of the evidence for bundled payments has been drawn from models in the traditional Medicare program. Although private insurers are increasingly offering bundled payment programs, it is not known whether they are associated with changes in episode spending and quality. To evaluate whether a voluntary bundled payment program offered by a national Medicare Advantage insurer was associated with changes in episode spending or quality of care for beneficiaries receiving lower extremity joint replacement (LEJR) surgery. Cross-sectional study of 23 034 LEJR surgical episodes that emulated a stepped-wedge design by using the time-varying, geographically staggered rollout of the bundled payment program from January 1, 2012, to September 30, 2019. Episode-level multivariable regression models were estimated within practice to compare changes before and after program participation, using episodes at physician practices that had not yet begun participating in the program during a given time period (but would go on to do so) as the control. Data analyses were performed from July 1, 2021, to June 30, 2022. Physician practice participation in the bundled payment program. The primary outcome was episode spending (plan and beneficiary). Secondary outcomes included postacute care use (skilled nursing facility and home health care), surgical setting (inpatient vs outpatient), and quality (90-day complications [including deep vein thrombosis, wound infection, fracture, or dislocation] and readmissions). The final analytic sample included 23 034 LEJR episodes (6355 bundled episodes and 16 679 control episodes) from 109 physician practices participating in the program. Of the beneficiaries, 7730 were male and 15 304 were female, 3057 were Black, 19 351 were White, 447 were of other race or ethnicity (assessed according to the Centers for Medicare & Medicaid Services beneficiary race and ethnicity code, which reflects data reported to the Social Security Administration), and 179 were of unknown race and ethnicity. The mean (SD) age was 70.9 (7.2) years. Participation in the bundled payment program was associated with a 2.7% (95% CI, 1.3%-4.1%) decrease in spending per episode (mean episodic spending, $21 964 [95% CI, $21 636-$22 296] vs $22 562 [95% CI, $22 346-$22 779]), as well as reductions in skilled nursing facility use after discharge (21.3% for bundled episodes vs 25.0% for control episodes; odds ratio [OR], 0.81 [95% CI, 0.67-0.98]) and increased use of the outpatient surgical setting (14.1% for bundled episodes vs 8.4% for control episodes; OR, 1.79 [95% CI, 1.53-2.09]). The program was not associated with changes in quality outcomes, including 90-day complications (8.8% for bundled episodes vs 8.6% for control episodes; OR, 1.02 [95% CI, 0.86-1.20]) and readmissions (4.3% for bundled episodes vs 4.6% for control episodes; OR, 0.92 [95% CI, 0.75-1.13]). In this study of an LEJR bundled payment program offered by a national Medicare Advantage insurer, findings suggest that physician practice participation in the program was associated with a decrease in episode spending without changes in quality. Bundled payments offered by private insurers, including Medicare Advantage plans, are an alternate payment option to fee for service that may reduce spending for LEJR episodes while maintaining quality of care.

Background Postoperative pneumonia is the most common healthcare-associated infection in cardiac surgical patients, yet their impact across a 90-day episode of care remains unknown. Our objective was to examine the relationship between pneumonia and 90-day episode payments and outcomes among Medicare beneficiaries undergoing cardiac surgery. Methods and Results Medicare claims were used to identify beneficiaries with episodes of coronary artery bypass grafting (CABG; n=56 728) and valve surgery (n=56 377) across 1045 centers between April 2014 and March 2015. Using a published diagnosis code-based algorithm, we identified pneumonia in 6.4% CABG episodes and 6.6% of valve surgery episodes. We compared price-standardized 90-day episode payments and outcome measures (postoperative length of stay, discharge to postacute care, mortality, and readmission) between beneficiaries with and without pneumonia using hierarchical regression models, adjusting for patient factors and hospital random effects. Pneumonia was associated with 24.5% higher episode payments for CABG ($46 723 versus $37 496; P<0.001) and 26.5% higher episode payments for valve surgery ($61 544 versus $48 549; P<0.001). For both cohorts, pneumonia was significantly associated with longer postoperative length of stay (CABG: +4.1 days, valve: +5.6 days), more frequent discharge to postacute care (CABG: odds ratio [OR]=1.99, valve: OR=2.17), and higher rates of 30-day mortality (CABG: OR=2.42, valve: OR=2.57) and 90-day readmission (CABG: OR=1.20, valve: OR=1.25), all P<0.001. We compared episode payments and outcomes across terciles of pneumonia rates and found that high pneumonia rate hospitals had higher episode payments and poorer outcomes compared with episodes at low pneumonia rate hospitals in both CABG and valve surgery cohorts. Conclusions Postoperative pneumonia was associated with significantly higher 90-day episode payments and inferior outcomes at the patient and hospital level. Future work should examine whether reducing pneumonia after cardiac surgery reduces episode spending and improves outcomes, which could facilitate hospital success in value-based reimbursement programs.

To evaluate sources of 90-day episode spending variation in Medicare patients undergoing bariatric surgery and whether spending variation was related to quality of care. Medicare's bundled payments for care improvement-advanced program includes the first large-scale episodic bundling program for bariatric surgery. This voluntary program will pay bariatric programs a bonus if 90-day spending after surgery falls below a predetermined target. It is unclear what share of bariatric episode spending may be due to unnecessary variation and thus modifiable through care improvement. Retrospective analysis of fee-for-service Medicare claims data from 761 acute care hospitals providing inpatient bariatric surgery between January 1, 2011 and September 30, 2016. We measured associations between patient and hospital factors, clinical outcomes, and total Medicare spending for the 90-day bariatric surgery episode using multivariable regression models. Of 64,537 patients, 46% underwent sleeve gastrectomy, 22% revisited the emergency department (ED) within 90 days, and 12.5% were readmitted. Average 90-day episode payments were $14,124, ranging from $12,220 at the lowest-spending quintile of hospitals to $16,887 at the highest-spending quintile. After risk adjustment, 90-day episode spending was $11,447 at the lowest quintile versus $15,380 at the highest quintile (difference $3932, P < 0.001). The largest components of spending variation were readmissions (44% of variation, or $2043 per episode), post-acute care (19% or $871), and index professional fees (15% or $450). The lowest spending hospitals had the lowest complication, ED visit, post-acute utilization, and readmission rates (P < 0.001). In this retrospective analysis of Medicare patients undergoing bariatric surgery, the largest components of 90-day episode spending variation are readmissions, inpatient professional fees, and post-acute care utilization. Hospitals with lower spending were associated with lower rates of complications, ED visits, post-acute utilization, and readmissions. Incentives for improving outcomes and reducing spending seem to be well-aligned in Medicare's bundled payment initiative for bariatric surgery.

To evaluate inter-hospital variation in 90-day total episode spending for sepsis, estimate the relative contributions of each component of spending, and identify drivers of spending across the distribution of episode spending on sepsis care. Medicare fee-for-service claims for beneficiaries (n=324,694) discharged from acute care hospitals for sepsis, defined by MS-DRG, between October 2014 and September 2018. Multiple linear regression with hospital-level fixed effects was used to identify average hospital differences in 90-day episode spending. Separate multiple linear regression and quantile regression models were used to evaluate drivers of spending across the episode spending distribution. The mean total episode spending among hospitals in the most expensive quartile was $30,500 compared with $23,150 for the least expensive hospitals ( P <0.001). Postacute care spending among the most expensive hospitals was almost double that of least expensive hospitals ($7,045 vs. $3,742), accounting for 51% of the total difference in episode spending between the most expensive and least expensive hospitals. Female patients, patients with more comorbidities, urban hospitals, and BPCI-A-participating hospitals were associated with significantly increased episode spending, with the effect increasing at the right tail of the spending distribution. Inter-hospital variation in 90-day episode spending on sepsis care is driven primarily by differences in post-acute care spending.

Objective: Pneumonia is the most common healthcare-associated infection following cardiac surgery, and associated with poorer clinical outcomes and substantially higher hospital costs. Less understood is the role that the care and treatment of post-operative pneumonia may have on a hospital’s 90-day episode payments. We hypothesize that expenditures associated with pneumonia may significantly impact a hospital’s 90-day episode payments for coronary artery bypass graft (CABG) surgery. Methods and Results: Using Medicare Part A and B claims data, we identified 49,573 patients undergoing isolated CABG in 1,001 hospitals with greater than 10 cases (2014-15). We applied an established claims-based algorithm to identify 3,135 (6.3%) patients as having a new onset of pneumonia during their index admission and after their surgical procedure. Using hierarchical logistic regression models, we estimated risk-adjusted hospital-level pneumonia rates, adjusted for age, sex, race, Medicaid eligibility, Elixhauser comorbidities, and hospital-random effect. There was weak correlation (r=0.20, p&lt;0.001) between observed and predicted (adjusting for only patient factors) hospital-level pneumonia rates, indicating patient factors explained little of the variation between hospitals. We placed patients into quartiles based on rank-order of hospital risk-adjusted pneumonia rates; the pneumonia rate in the lowest and highest quartile was 3.4% and 13.9% (p&lt;0.001), respectively (Table). Average risk-adjusted 90-day episode expenditures were 10% higher for patients in the highest quartile hospitals compared to the lowest quartile ($41,936 vs. $46,095 vs., p&lt;0.001). Payments for outlier hospitalizations were 100% greater in the highest quartile hospitals compared to the lowest quartile, and accounted for 28.5% of the total difference between high and low spending hospitals. Conclusion: New onset pneumonia after cardiac surgery varies widely across hospitals, and counter to conventional wisdom, is not driven by patient risk. Cardiac surgical programs should consider the prevention and management post-operative pneumonia as a component of their overall strategy for reducing 90-day episode payments.

Ensuring patients have adequate physiological reserves to meet the demands of major surgery may necessitate nutritional prehabilitation and perioperative medical nutrition therapy (MNT). Parenteral nutrition (PN) via central or peripheral routes is indicated when requirements cannot be met orally or enterally. While patients undergoing major gastrointestinal (GI) surgery are at high nutritional and catabolic risk, guidance on PN is limited in Enhanced Recovery After Surgery (ERAS) protocols. This survey-based study characterized MNT practices among GI surgeons, and the challenges and opportunities for MNT within the context of ERAS. This on-line survey comprised questions and attitudinal statements centred on MNT, particularly PN, for major GI surgery patients, and encompassed the spectrum of the surgical pathway (prehabilitation to postoperative care). GI surgeons in Europe were invited to complete the survey. Respondents described their current clinical practices, while their perceptions, unmet needs, and opportunities to improve nutritional management were explored via Likert-scale responses to statements. GI surgeons (N=130) from different centres in France, Germany, Italy, Poland, and Spain completed the survey. Enhanced recovery protocols (75%) and multidisciplinary nutritional care teams (72%) were established in the centres of most respondents; surgeons, dieticians/nutritionists, and nurses were most frequently involved in MNT. Nutritional risk screening was common in the centres surveyed prior to surgery (range: 62% in Italy to 96% in Poland) and undertaken less frequently postoperatively (range: 19% in Poland to 54% in Germany) with varied screening methods. Enteral nutrition insufficiency was the most common reason for prescribing PN (83%) and 56% of surgeons prescribed PN when enteral nutrition (EN) was not feasible. Overall, 71% of respondents agreed that peripherally administered PN (PPN), which does not require a central access route, lessens invasive procedures and benefits selected patients who are in a catabolic state, malnourished, or at nutritional/metabolic risk when oral intake/EN is insufficient. However, only 35% of surgeons used PPN in this scenario and only 47% utilized PPN when a central venous catheter is not available. Most surgeons (69%) agreed that PPN is in line with the ERAS concept of using minimally invasive approaches. The respondents raised a need for increasing awareness of PPN indications (81%), inclusion of PPN recommendations in clinical guidelines (79%), implementation of nutritional support teams (79%), and increased PPN-trained personnel (78%) to improve PPN delivery. PPN is perceived by surgeons (with ≥10 patients per month who receive PN) as a favourable strategy to support timely nutritional support in selected patients undergoing major GI surgery. However, from this clinical practice survey it seems PPN is underutilized in nutritional care practices. Findings from this survey of GI surgeons in Europe emphasize the need to improve early identification of patients who are malnourished or at nutritional/metabolic risk and integrate PPN into ERAS GI surgical pathways, within the framework of minimally invasive approaches.

Total joint arthroplasty (TJA) has been identified as a procedure with substantial variations in inpatient and postacute care payments. Most studies in this area have focused primarily on the Medicare population and rarely have characterized the younger commercially insured populations. Understanding the inpatient and postdischarge care service-componentdifferences across 90-day episodes of care and factors associated with payments for younger patients is crucial for successful implementation of bundled payments in TJA in non-Medicare populations. (1) To assess the mean total payment for a 90-day primary TJA episode, including the proportion attributable to postdischarge care, and (2) to evaluate the role of procedure, patient, and hospital-level factors associated with 90-day episode-of-care payments in a non-Medicare patient population younger than 65 years. Claims data for 2008 to 2013 from Blue Cross Blue Shield of Texas were obtained for primary TJAs. A total of 11,131 procedures were examined by aggregating payments for the index hospital stay and any postacute care including rehabilitation services and unplanned readmissions during the 90-day postdischarge followup period. A three-level hierarchical model was developed to determine procedure-, patient-, and hospital-level factors associated with 90-day episode-of-care payments. The mean total payment for a 90-day episode for TJA was USD 47,700 adjusted to 2013 USD. Only 14% of 90-day episode payments in our population was attributable to postdischarge-care services, which is substantially lower than the percentage estimated in the Medicare population. A prolonged length of stay (rate ratio [RR], 1.19; 95% CI, 1.15-1.23; p ≤ 0.001), any 90-day unplanned readmission (RR, 1.64; 95% CI, 1.57-1.71; p ≤ 0.001), computer-assisted surgery (RR, 1.031; 95% CI, 1.004-1.059; p ≤ 0.05), initial home discharge with home health component (RR, 1.029; 95% CI, 1.013-1.046; p ≤ 0.001), and very high patient morbidity burden (RR, 1.105; 95% CI, 1.062-1.150; p ≤ 0.001) were associated with increased TJA payments. Hospital-level factors associated with higher payments included urban location (RR, 1.29; 95% CI, 1.17-1.42; p ≤ 0.001), lower hospital case mix based on average relative diagnosis related group weight (RR, 0.94; 95% CI, 0.89-0.95; p ≤ 0.001), and large hospital size as defined by total discharge volume (RR, 1.082; 95% CI, 1.009-1.161; p ≤ 0.05). All procedure, patient, and hospital characterizing factors together explained 11% of variation among hospitals and 49% of variation among patients. Inpatient care contributed to a much larger proportion of total payments for 90-day care episodes for primary TJA in our younger than 65-year-old commercially insured population. Thus, inpatient care will continue to be an essential target for cost-containment and delivery strategies. A high percentage of hospital-level variation in episode payments remained unexplained by hospital characteristics in our study, suggesting system inefficiencies that could be suitable for bundling. However, replication of this study among other commercial payers in other parts of the country will allow for conclusions that are more robust and generalizable. Level II, economic analysis.

Objective: U.S. healthcare spending is rising, driven in large part by spending on cardiovascular disease. In response, the Centers for Medicare&amp;Medicaid Services (CMS) is implementing payment models to incentivize more efficient care. The Transforming Episode Accountability Model (TEAM) is a mandatory bundled payment model launching in 2026. Hospitals will be accountable for spending on episodes of care, spanning admission to 30 days after discharge, for 5 surgeries, including coronary artery bypass grafts (CABGs). If they meet spending targets, they will receive a financial bonus from CMS; if not, they must pay a penalty. Little is known about the hospitals mandated to participate in TEAM. Understanding how participants differ from nonparticipants is important as CMS scales insights from TEAM to the broader cardiovascular payment landscape. Design: We identified TEAM participation from CMS and hospital characteristics from the American Hospital Association survey, Area Health Resources File, and Medicare enrollment and claims data. t -tests compared characteristics. Findings: We identified 716 hospitals in TEAM. Compared to nonparticipants, participants were larger (263 vs 214 beds), more often urban (100.0% vs 90.6%), and part of the safety net (14.4% vs 8.3%). Participants served a higher share of patients dually enrolled in Medicare and Medicaid. 30-day episode spending ranged from $29,778 for lower extremity joint replacements to $50,092 for CABGs, but for all bundles, spending was higher among participants than nonparticipants. The contribution of post-acute care (PAC) spending to episode spending varied from $5,705 (11.4% of 30-day spending) for CABG to $21,556 (50.1% of 30-day spending) for hip/femur fracture bundles. Conclusions: Hospitals mandated to participate in TEAM were larger, more urban, cared for a higher share of marginalized patients, and were more often part of the safety net. This raises concerns that such hospitals, which have fared poorly in prior payment models, could bear disproportionate penalties under TEAM. In addition, our results suggest that spending reductions might be heterogeneous across bundles. Bundled payment participants generally reduce overall episode spending by reducing PAC spending. Greater spending reductions might thus be expected in procedures for which we found PAC to represent a greater portion of episode spending, such as the hip/femur fracture bundle, as opposed to the CABG bundle.

P72. Drivers of episode payments for non-cervical spinal fusion

30-Day Episode Payments and Heart Failure Outcomes Among Medicare Beneficiaries

We sought to measure the extent of variation in episode spending around total hip replacement within and across hospital systems. Bundled payment programs are pressuring hospitals to reduce spending on surgery. Meanwhile, many hospitals are joining larger health systems with the stated goal of improved care at lower cost. Cross-sectional study of fee-for-service Medicare patients undergoing total hip replacement in 2016 at hospital systems identified in the American Hospital Association Annual Survey. We calculated risk- and reliability-adjusted average 30-day episode payments at the hospital and system level. Average episode payments varied nearly as much within hospital systems ($2515 between the lowest- and highest-cost hospitals, 95% confidence interval $2272-$2,758) as they did between the lowest- and highest-cost quintiles of systems ($2712, 95% confidence interval $2545-$2879). Variation was driven by post-acute care utilization. Many systems have concentrated hip replacement volume at relatively high-cost hospitals. Given the wide variation in surgical spending within health systems, we propose tailored strategies for systems to maximize savings in bundled payment programs.

Nutrition Screening: Coding after Discharge Underestimates the Prevalence of Undernutrition

Introduction: Outpatient follow-up after heart failure hospitalization has been shown to reduce readmission and emergency department (ED) visits. Hypothesis: We sought to evaluate the use of virtual follow up-care heart failure hospitalizations in a commercially insured population. Methods: We queried the Michigan Value Collaborative multipayer claims database for heart failure hospitalizations in patients discharged to home or home health between 7/20-11/20. We identified follow-up visits as outpatient office visits within 30 days of discharge, and categorized each patient as having an in-person only, virtual-only (GT or 95 modifier code), both virtual and in-person, and no follow-up visit. Multivariable logistic and linear regression was used to evaluate the association between follow-up visit type and 30-day readmissions, ED visits, and price-standardized episode spending. Results: A total of 2415 patients were discharged alive after a heart failure hospitalization: 94 (3.9%) patients had a virtual-only follow-up visit, 258 (10.7%) had both in-person and virtual visits, 1551 (64.2%) had in-person only follow-up visits, and 512 (21.2%) had no follow-up within 30 days of discharge. Adjusted analyses revealed that patients receiving both virtual and in-person visits had similar rates of 30-day readmissions (aOR=0.73, 95% CI: 0.42, 1.27), ED visits (aOR=0.52, 0.26, 1.07), and episode spending (adjusted difference= -$1508, 95% CI: -$3835, $821; Table ). However, patients receiving only virtual visits or no follow-up had significantly higher 30-day readmissions (aOR=2.31, 95% CI: 1.21, 4.42) and episode spending (adjusted difference= $1974, 95% CI: $206, $3742) compared to in-person visits. Conclusions: Virtual follow-up visits occurred in nearly 15% of heart failure patients, but had mixed results on patient outcomes. More evidence is needed to support the role of virtual-only follow-up visits after heart failure hospitalizations.