Bundled Payments For Care Improvement Research Articles

Hospital and Physician Group Practice Participation in Prior and Next-Generation Value-Based Payment Programs

This cohort study examines whether prior direct or indirect participation in the Centers for Medicare & Medicaid Innovation Bundled Payments for Care Improvement (BCPI) Initiative was associated with their participation in the next generation of the program.

Bundled Payments for Care Improvement and Quality of Care and Outcomes in Heart Failure

The Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) program was launched in 2013 with a goal to improve care quality while lowering costs to Medicare. To compare changes in the quality and outcomes of care for patients hospitalized with heart failure according to hospital participation in the BPCI program. This cross-sectional study used a difference-in-difference approach to evaluate the BPCI program in 18 BPCI hospitals vs 211 same-state non-BPCI hospitals for various process-of-care measures and outcomes using American Heart Association Get With The Guidelines-Heart Failure registry and CMS Medicare claims data from November 1, 2008, to August 31, 2018. Data were analyzed from May 2022 to May 2023. Hospital participation in CMS BPCI Model 2 Heart Failure, which paid hospitals in a fee-for-service process and then shared savings or required reimbursement depending on how the total cost of an episode of care compared with a target price. Primary end points included 7 quality-of-care measures. Secondary end points included 9 outcome measures, including in-hospital mortality and hospital-level risk-adjusted 30-day and 90-day all-cause readmission rate and mortality rate. During the study period, 8721 patients were hospitalized in the 23 BPCI hospitals and 94 530 patients were hospitalized in the 224 same-state non-BPCI hospitals. Less than a third of patients (30 723 patients, 29.8%) were 75 years or younger; 54 629 (52.9%) were female, and 48 622 (47.1%) were male. Hospital participation in BPCI Model 2 was not associated with significant differential changes in the odds of various process-of-care measures, except for a decreased odds of evidence-based β-blocker at discharge (adjusted odds ratio [aOR], 0.63; 95% CI, 0.41-0.98; P = .04). Participation in the BPCI was not associated with a significant differential change in the odds of receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors at discharge, receiving an aldosterone antagonist at discharge, having a cardiac resynchronization therapy (CRT)-defibrillator or CRT pacemaker placed or prescribed at discharge, having implantable cardioverter-defibrillator (ICD) counseling or an ICD placed or prescribed at discharge, heart failure education being provided among eligible patients, or having a follow-up visit within 7 days or less. Participation in the BPCI was associated with a significant decrease in odds of in-hospital mortality (aOR, 0.67; 95% CI, 0.51-0.86; P = .002). Participation was not associated with a significant differential change in hospital-level risk-adjusted 30-day or 90-day all-cause readmission rate and 30-day or 90-day all-cause mortality rate. In this study, hospital participation in the BPCI Model 2 Heart Failure program was not associated with improvement in process-of-care quality measures or 30-day or 90-day risk-adjusted all-cause mortality and readmission rates.

Effectiveness of Transitional Care Program among High-Risk Discharged Patients: A Quasi-Experimental Study on Saving Costs, Post-Discharge Readmissions and Emergency Department Visits

Transitional care programs (TCPs), where hospital care team members repeatedly follow up with discharged patients, aim to reduce post-discharge hospital or emergency department (ED) utilization and healthcare costs. We examined the effectiveness of TCPs at reducing healthcare costs, hospital readmissions, and ED visits. Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement (BPCI) program adjudicated claims files and electronic health records from Greenville Memorial Hospital, Greenville, SC, were accessed. Data on post-discharge 30- and 90-day ED visits and readmissions, total costs, and episodes with costs over BPCI target prices were extracted from November 2017 to July 2020 and compared between the “TCP-Graduates” (N = 85) and “Did Not Graduate” (DNG) (N = 1310) groups. As compared to the DNG group, the TCP-Graduates group had significantly fewer 30-day (7.1% vs. 14.9%, p = 0.046) and 90-day (15.5% vs. 26.3%, p = 0.025) readmissions, episodes with total costs over target prices (25.9% vs. 36.6%, p = 0.031), and lower total cost/episode (USD 22,439 vs. USD 28,633, p = 0.018), but differences in 30-day (9.4% vs. 11.2%, p = 0.607) and 90-day (20.0% vs. 21.9%, p = 0.680) ED visits were not significant. TCP was associated with reduced post-discharge hospital readmissions, total care costs, and episodes exceeding target prices. Further studies with rigorous designs and individual-level data should test these findings.

Abstract 16083: How Will the Use of New Heart Failure Treatments Impact US Health System Reimbursement Under Alternative Payment Models: Measuring the Impact of Sotagliflozin Use Among Patients Hospitalized for Heart Failure

Background: In the SOLOIST-WHF clinical trial, sotagliflozin lowered rates of readmission and emergency department (ED) visits among patients hospitalized for worsening heart failure (HF), but its impact on health systems’ finances is unclear. Research Question: What is the economic impact of the adoption of sotagliflozin on health systems after incorporating reimbursement bonuses within alternative payment models (APM)? Goal: To quantify the financial impact on health systems of adopting sotagliflozin relative to standard of care (SoC) for treating patients with HF as in SOLOIST-WHF. Methods: This study created a decision tree model and estimated the clinical impact of sotagliflozin use relative to SoC from the SOLOIST-WHF trial. The model first assessed the impact of sotagliflozin on re-hospitalization, ED visit rates and mortality. Next, these clinical outcomes were translated into impacts on a health system’s finances relative to SoC within a one-year time frame under traditional fee-for-services (FFS) and three APMs: hospital readmissions reduction program (HRRP), Bundled Payments for Care Improvement (BPCI), and Accountable Care Organization (ACO). Results: An average community hospital (6,109 admissions annually) would have 83 patients per year with an index HF hospitalization. Sotagliflozin reduced the probability of re-hospitalization, ED visits, and deaths by 29.3%, 38.5%, and 17.8%, respectively vs. SoC. For hospitals not experiencing capacity constraint, sotagliflozin adoption increased financial returns by $9,365 per person (pp) ($781,340 per health system) under HRRP, $1,200 pp. ($100,106 per health system) for BPCI, and $1,078 pp. ($89,910 per health system) for ACO. (Figure 1) Conclusion: Sotagliflozin adoption decreased hospitalizations, ED visits, and deaths, which—under various APMs—led to a net positive financial impact on health systems after accounting for APM bonus payments. Sponsorship: Lexicon Pharmaceuticals, Inc.

The Association Between Facility Affiliations and Revenue Generation in Skilled Nursing Facilities - An Exploratory Study.

Although hospitals have been the traditional setting for interventional and rehabilitative care, skilled nursing facilities (SNFs) can offer a high-quality and less costly alternative than hospitals. Unfortunately, the financial health of SNFs is often a matter of concern. To partially address these issues, SNF leaders have increased engagement in a number of affiliations to assist in improving quality and reducing operational costs, including Accountable Care Organizations (ACOs), Health Information Exchanges (HIEs), and participation in Bundled Payment for Care Improvement (BPCI) programs. What is not well understood is what impact these affiliations have on the financial viability of the host organizations. Given these factors, this study aims to identify what association, if any, exists between SNF affiliations and revenue generation. Data from calendar year 2022 for n=13,447 SNFs in the US were assessed using multivariate regression analysis. We evaluated two separate dependent measures of revenue generation capacity: net patient revenue per bed and net patient revenue per discharge and considered three unique facility affiliations including (1) ACOs, (2) HIEs, and (3) BPCI participants. Six multivariable linear regressions revealed that ACO affiliation is negatively associated with revenue generation on both dependent measures, while HIE affiliation and BPCI participation reflected mixed results. A better understanding of the financial impact of SNFs' affiliations may prove insightful. By carefully considering the value of each affiliation, and how each is applicable to any given market, policymakers, funding agencies, and facility leaders may be able to better position SNFs for more sustainable financial performance in a challenging economic environment.

Association between Hospital Participation in Value-Based Programs and Timely Initiation of Post-Acute Home Health Care, Functional Recovery, and Hospital Readmission after Joint Replacement.

This study examined the association between hospital participation in Bundled Payments for Care Improvement (BPCI) or Comprehensive Care for Joint Replacement (CJR) and the timely initiation of home health rehabilitation services for lower extremity joint replacements. Furthermore, this study examined the association between the timely initiation of home health rehabilitation services with improvement in self-care, mobility, and 90-day hospital readmission. This retrospective cohort study used Medicare inpatient claims and home health assessment data from 2016-2017 for older adults discharged to home with home health following hospitalization after joint replacement. Multilevel multivariate logistic regression was used to examine the association between hospital participation in BPCI or CJR programs and timely initiation of home health rehabilitation service. A two-staged generalized boosted model was used to examine the association between latency and improvement in self-care, mobility, and 90-day risk-adjusted hospital readmission. Compared with patients discharged from hospitals that did not have BPCI or CJR, patients discharged from hospitals with these programs had a lower likelihood of delayed initiation of home health rehabilitation services for both knees and hip replacement. Using propensity scores as the inverse probability of treatment weights, delay in the initiation of home health rehabilitation services was associated with lower improvement in self-care (odds ratio [OR] = 1.23; 95% CI = 1.20 to 1.26), mobility (OR = 1.15; 95% CI = 1.13 to 1.18), and higher rate of 90-day hospital readmission (OR = 1.19; 95% CI = 1.15 to 1.24) for knee replacement. Likewise, delayed initiation of home health rehabilitation services was associated with lower improvement in self-care (OR = 1.16; 95% CI = 1.13 to 1.20) and mobility (OR = 1.26; 95% CI = 1.22 to 1.30) for hip replacement. Hospital participation in bundled payments for care improvement or comprehensive care for joint replacement was associated with early home health rehabilitation care initiation, which was further associated with significant increases in functional recovery and lower risks of hospital readmission. Policy makers may consider incentivizing health care providers to initiate early home health services and care coordination in value-based payment models.

Performance of Physician Groups and Hospitals Participating in Bundled Payments Among Medicare Beneficiaries

Hospital participation in bundled payment initiatives has been associated with financial savings and stable quality of care. However, how physician group practices (PGPs) perform in bundled payments compared with hospitals remains unknown. To evaluate the association of PGP participation in the Bundled Payments for Care Improvement (BPCI) initiative with episode outcomes and to compare these with outcomes for participating hospitals. This cohort study with a difference-in-differences analysis used 2011 to 2018 Medicare claims data to compare the association of BPCI participation with episode outcomes for PGPs vs hospitals providing medical and surgical care to Medicare beneficiaries. Data analyses were conducted from January 1, 2020, to May 31, 2022. Hospitalization for any of the 10 highest-volume episodes (5 medical and 5 surgical) included in the BPCI initiative for Medicare patients of participating PGPs and hospitals. The primary outcome was 90-day total episode spending. Secondary outcomes were 90-day readmissions and mortality. The total sample comprised data from 1 288 781 Medicare beneficiaries, of whom 696 710 (mean [SD] age, 76.2 [10.8] years; 432 429 [59.7%] women; 619 655 [85.5%] White individuals) received care through 379 BPCI-participating hospitals and 1441 propensity-matched non-BPCI-participating hospitals, and 592 071 (mean [SD] age, 75.4 [10.9] years; 527 574 [86.6%] women; 360 835 [59.3%] White individuals) received care from 6405 physicians in BPCI-participating PGPs and 24 758 propensity-matched physicians in non-BPCI-participating PGPs. For PGPs, BPCI participation was associated with greater reductions in episode spending for surgical (difference, -$1368; 95% CI, -$1648 to -$1088) but not for medical episodes (difference, -$101; 95% CI, -$410 to $206). Hospital participation in BPCI was associated with greater reductions in episode spending for both surgical (-$1010; 95% CI, -$1345 to -$675) and medical (-$763; 95% CI, -$1139 to -$386) episodes. This cohort study and difference-in-differences analysis of PGPs and hospital participation in BPCI found that bundled payments were associated with cost savings for surgical episodes for PGPs, and savings for both surgical and medical episodes for hospitals. Policy makers should consider the comparative performance of participant types when designing and evaluating bundled payment models.

Succeeding in Medicare’s newest bundled payment program: Results from teaching hospitals

BackgroundIn 2018, Medicare implemented a successor to its Bundled Payments for Care Improvement (BPCI) program, BPCI Advanced, with stricter participation rules and new financial incentives to reduce spending. MethodsUsing claims-based episode data from thirteen participants, we compared spending and utilization in the first fifteen months of the new program (October 2018 to December 2019) to hospital- and episode-specific target prices, with a deep dive into clinical correlates for the most commonly-selected clinical episodes, sepsis and congestive heart failure. ResultsTwelve out of thirteen participants in a collaborative of teaching hospitals achieved shared savings for both Medicare and their own institution. Aggregate hospital shared savings were 5.8% of benchmark prices across 6,131 patients in 16 clinical episodes (p<0.001), appreciably higher than the reference savings rates reported after the first period of Medicare’s predecessor BPCI program. Differences in shared savings across hospitals for sepsis and congestive heart failure correlated with reductions in patients’ use of post-acute care, including reductions in skilled nursing facility, readmission, and home health rates. Evidence is presented showing reductions in patient utilization for cost-intensive post-acute settings accompanied increases in the proportion of patients exclusively utilizing non-institutional care after discharge from an anchor stay or procedure. ConclusionsThese findings provide an example of the fulfillment of a core promise of bundled payments to uncover new opportunities for reduced spending. Level of evidenceNon-random cohort of hospitals.

Association of Skilled Nursing Facility Participation in Voluntary Bundled Payments With Postacute Care Outcomes for Joint Replacement.

The Medicare Bundled Payments for Care Improvement (BPCI) model 3 of 2013 holds participating skilled nursing facilities (SNFs) responsible for all episode costs. There is limited evidence regarding SNF-specific outcomes associated with BPCI. To examine the association between SNF BPCI participation and patient outcomes and across-facility differences in these outcomes among Medicare beneficiaries undergoing lower extremity joint replacement (LEJR). Observational difference-in-differences (DID) study of 2013-2017 for 330 unique persistent-participating SNFs, 146 unique dropout SNFs, and 14,028 unique eligible nonparticipating SNFs. Rehospitalization within 30 and 90 days after SNF admission, and rate of successful discharge from the SNF to the community. Total 636,355 SNF admissions after LEJR procedures were identified for 582,766 Medicare patients [mean (SD) age, 76.81 (9.26) y; 424,076 (72.77%) women]. The DID analysis showed that for persistent-enrollment SNFs, no BPCI-related changes were found in readmission and successful community discharge rates overall, but were found for their subgroups. Specifically, under BPCI, the 30-day readmission rate decreased by 2.19 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, and by 1.75 percentage-points for non-Medicaid-dependent SNFs in the persistent-participating group relative to those in the nonparticipating group; and the rate of successful community discharge increased by 4.44 percentage-points for White-serving SNFs in the persistent-participating group relative to those in the nonparticipating group, whereas such relationship was not detected among non-White-serving SNFs, leading to increased between-facility differences (differential DID=-7.62). BPCI was not associated with readmission or successful community discharge rates for dropout SNFs, overall, or in subgroup analyses. Among Medicare patients receiving LEJR, BPCI was associated with improved outcomes for White-serving/non-Medicaid-dependent SNFs but not for other SNFs, which did not help reduce or could even worsen the between-facility differences.

Skilled Nursing Facility Participation in Bundled Payments Was Related to Small Increases in Nurse Staffing Levels.

Medicare implemented Bundled Payments for Care Improvement (BPCI) Model 3 in 2013, in which participating skilled nursing facilities (SNFs) were accountable for episode costs. We performed comparative interrupted time series analyses to evaluate associations between SNF BPCI participation and nurse staffing levels, using Medicare claims, resident assessments, and facility-level and market-level files of 2010-2017. For persistent-participating SNFs, BPCI was associated with improved certified nursing assistant (CNA) staffing levels (differential change = .03hours, p = .025). However, BPCI was not related to changes in registered nurse (RN) and all licensed nurse hours, and nurse skill mix. Among drop-out SNFs, BPCI was associated with increased RN staffing levels (differential change = .02hours, p = .009), leading to a higher nurse skill ratio (0.51 percentage points, p = .016) than control SNFs. Bundled payments for care improvement had no impact on CNA and all licensed nurse staffing levels. In conclusion, BPCI was associated with statistically significant but small increases in nurse staffing levels.

Demographics and Medical Comorbidities as Risk Factors for Increased Episode of Care Costs Following Lumbar Fusion in Medicare Patients.

The objective was to evaluate medical comorbidities and surgical variables as independent risk factors for increased health care costs in Medicare patients undergoing lumbar fusion. Care episodes limited to lumbar fusions were retrospectively reviewed on the Centers of Medicare and Medicaid Innovation (CMMI) Bundled Payment for Care Improvement (BPCI) reimbursement database at a single academic institution. Total episode of care cost was also collected. A multivariable linear regression model was developed to identify independent risk factors for increased total episode of care cost, and logistic models for surgical complications and readmission. A total of 500 Medicare patients were included. Risk factors associated with increased total episode of care cost included transforaminal interbody fusion (TLIF) and anterior lumbar interbody fusion (ALIF) (β = $5,399, P < 0.001) and ALIF+PLF (AP) fusions (β = $24,488, P < 0.001), levels fused (β = $3,989, P < 0.001), congestive heart failure (β = $6,161, P = 0.022), hypertension with end-organ damage (β = $10,138, P < 0.001), liver disease (β = $16,682, P < 0.001), inpatient complications (β = $4,548, P = 0.001), 90-day complications (β = $10,012, P = 0.001), and 90-day readmissions (β = $15,677, P < 0.001). The most common surgical complication was postoperative anemia, which was associated with significantly increased costs (β = $18,478, P < 0.001). Female sex (OR = 2.27, P = 0.001), AP fusion (OR = 2.59, P = 0.002), levels fused (OR = 1.45, P = 0.005), cerebrovascular disease (OR = 4.19, P = 0.003), cardiac arrhythmias (OR = 2.32, P = 0.002), and fluid electrolyte disorders (OR = 4.24, P = 0.002) were independent predictors of surgical complications. Body mass index (OR = 1.07, P = 0.029) and AP fusions (OR = 2.87, P = 0.049) were independent predictors of surgical readmission. Among medical comorbidities, congestive heart failure, hypertension with end-organ damage, and liver disease were independently associated with a significant increase in total episode of care cost. Interbody devices were associated with increased admission cost.

Impact of a pharmacist-driven transitions of care clinic for a multisite integrated delivery network.

To assess the impact on readmission rates for CMS core measures (CCM) patients and patients receiving care under the Bundled Payment for Care Improvement (BPCI) Advanced Model resulting from implementing a pharmacist-led transitions of care (TOC) clinic in central Florida. These study cohorts consisted of patients in 2 strata (CCM and BPCI), and pre-post comparisons were conducted within each stratum. CCM and BPCI patient stratification was based on diagnoses. Patients referred to the TOC clinic were identified and compared to patients who did not receive TOC clinic services in the prior year. The pharmacist-led TOC clinic services consisted of a postdischarge telephone interview by a pharmacist to identify TOC barriers. Pharmacists in the TOC clinic conducted medication reconciliations, provided education, and completed follow-up telephone visits to mitigate these barriers. The primary outcome was the 30-day readmission rate for CCM patients and 90-day readmission rate for BPCI patients. The secondary outcomes were the numbers and types of interventions performed in the pharmacist-led TOC clinic. A total of 1,203 patients met the inclusion criteria for the CCM stratum. The CCM post-group had an overall reduction in the rate of 30-day readmission relative to the pre-group (6.25% vs 13.29%, P < 0.0327). A total of 1,416 patients met the inclusion criteria for the BPCI strata. Relative to the BPCI pre-group, the BPCI post-group had an overall reduction in occurrence of 90-day readmission (17.27% vs 25.61%, P < 0.0306). Clinical pharmacists performed 456 interventions in the CCM and BPCI post-groups, with an average of 2 interventions per patient. A pharmacist-driven TOC clinic was associated with significant reductions in 30-day CCM and 90-day BPCI hospital readmissions.

Impact of Hospital-Based Rehabilitation Services on Discharge to the Community by Value-Based Payment Programs After Joint Replacement Surgery.

The purpose of this study was to examine the impact of hospital-based rehabilitation services on community discharge rates after hip and knee replacement surgery according to hospital participation in value-based care models: bundled payments for care improvement (BPCI) and comprehensive care for joint replacement (CJR). The secondary objective was to determine whether community discharge rates after hip and knee replacement surgery differed by participation in these models. A secondary analysis of Medicare fee-for-service claims was conducted for beneficiaries 65years of age or older who underwent hip and knee replacement surgery from 2016 to 2017. Independent variables were hospital participation in value-based programs categorized as: (1) BPCI, (2) CJR, and (3) non-BPCI/CJR; and total minutes per day of hospital-based rehabilitation services categorized into tertiles. The primary outcome variable was discharged to the community versus discharged to institutional post-acute care settings. The association between rehabilitation amount and community discharge among BPCI, CJR, and non-BPCI/CJR hospitals was adjusted for patient-level clinical and hospital characteristics. Participation in BPCI or CJR was not associated with community discharge. This analysis found a dose-response relationship between the amount of rehabilitation services and odds of community discharge. Among those who received a hip replacement, this relationship was most pronounced in the BPCI group; compared with the low rehabilitation category, the medium category had odds ratio (OR) = 1.28 (95% CI = 1.17 to 1.41), and the high category had OR = 1.90 (95% CI = 1.71 to 2.11). For those who received a knee replacement, there was a dose-response relationship in the CJR group only; compared with the low rehabilitation category, the medium category had OR = 1.21 (95% CI = 1.15 to 1.28), and the high category had OR = 1.56 (95% CI = 1.46 to 1.66). Regardless of hospital participation in BPCI or CJR models, higher amounts of rehabilitation services delivered during acute hospitalization is associated with a higher likelihood of discharge to community following hip and knee replacement surgery. In the era of value-based care, frontloading of rehabilitation care is vital for improving patient-centered health outcomes in acute phases of lower extremity joint replacement.

Medicare Bundled Payment Model for Total Ankle Arthroplasty

Category:Ankle; OtherIntroduction/Purpose:Total ankle arthroplasty (TAA) is included in the Centers of Medicare and Medicaid Services' (CMS) Bundled Payments for Care Improvement (BPCI) initiative for lower extremity joint replacements. This model has been demonstrated to be for total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, there remains concern that the model underestimates expected costs for TAA due to the unique healthcare needs of TAA patients including higher implant costs, longer procedures, and an increased demand for postoperative acute care services due to non-weightbearing. The purpose of this study was to analyze the breakdown of costs associated with inpatient and outpatient care and assess the difference between Medicare beneficiary reimbursements and actual costs for the episode of care.Methods:An IRB-approved retrospective review was conducted of patients with Medicare who underwent TAA between July 2014 and June 2018. The surgeries were performed at seven facilities affiliated with a singular institution hospital system. Patients undergoing TAA in this time period were identified using an institutional arthroplasty database and were eligible for study. Of 99 patients who met this criterion, financial data was available for 72. Demographics including age, gender, BMI, and comorbidities were collected via chart review. Episode start and end dates, first post-acute care discharge destination, and total episode costs were recorded. Total episode cost was subdivided into inpatient facility cost, surgeon fees, and post-acute care discharge costs (inpatient rehab facility costs, skilled nursing facility expenses, or home health aide fees). Patients were stratified into two groups based on 90-day costs of care, a 'positive group' not exceeding the bundled payment allocation and a 'negative group' which did exceed.Results:No statistically significant difference was found among demographics between the positive and negative patient groups. Average group age was 70.5 years and 72.9 years, respectively, and both groups had average BMI of 29.3 kg/m2. Age-adjusted Charlson Comorbidity Index was 3.35 for the positive group and 3.40 for the negative group. Total episode costs were 50% higher in the negative group compared to the positive group ($31,462 vs. $15,845). The total post discharge costs for the negative group were $17,912 which is significantly higher than those of the positive group ($2,502) (P<0.001). Thirteen patients (18.1%) attended skilled nursing facilities, and 12 of these patients exceeded the allocated budget. Average SNF cost was $13,089, which nearly matched the entire inpatient cost (facility + surgeon fees) of $13,400. Home health aide requirement was significant at 39% (n=28), and 15 of these patients (54%) also came in over budget.Conclusion:Results suggest that there is a considerable possibility for patients undergoing TAA to have post-acute care requirements that drive cost over budget, including admittance to skilled nursing facilities and home health aide, likely sue to the added necessity for extended immobilization in an older patient population. Such parameters should be factored into the BPCI reimbursement model for TAA.

Skilled Nursing Facility Participation in a Voluntary Medicare Bundled Payment Program: Association With Facility Financial Performance.

Model 3 of the Bundled Payments for Care Improvement (BPCI) is an alternative payment model in which an entity takes accountability for the episode costs. It is unclear how BPCI affected the overall skilled nursing facility (SNF) financial performance and the differences between facilities with differing racial/ethnic and socioeconomic status (SES) composition of the residents. The objective of this study was to determine associations between BPCI participation and SNF finances and across-facility differences in SNF financial performance. A longitudinal study spanning 2010-2017, based on difference-in-differences analyses for 575 persistent-participation SNFs, 496 dropout SNFs, and 13,630 eligible nonparticipating SNFs. Inflation-adjusted operating expenses, revenues, profit, and profit margin. BPCI was associated with reductions of $0.63 million in operating expenses and $0.57 million in operating revenues for the persistent-participation group but had no impact on the dropout group compared with nonparticipating SNFs. Among persistent-participation SNFs, the BPCI-related declines were $0.74 million in operating expenses and $0.52 million in operating revenues for majority-serving SNFs; and $1.33 and $0.82 million in operating expenses and revenues, respectively, for non-Medicaid-dependent SNFs. The between-facility SES gaps in operating expenses were reduced (differential difference-in-differences estimate=$1.09 million). Among dropout SNFs, BPCI showed mixed effects on across-facility SES and racial/ethnic differences in operating expenses and revenues. The BPCI program showed no effect on operating profit measures. BPCI led to reduced operating expenses and revenues for SNFs that participated and remained in the program but had no effect on operating profit indicators and mixed effects on SES and racial/ethnic differences across SNFs.

The Effect of Hospital Safety Net Status on the Association Between Bundled Payment Participation and Changes in Medical Episode Outcomes.

Under Medicare's Bundled Payments for Care Improvement (BPCI) program, hospitals have maintained quality and achieved savings for medical conditions. However, safety net hospitals may perform differently owing to financial constraints and organizational challenges. To evaluate whether hospital safety net status affected the association between bundled payment participation and medical episode outcomes. This observational difference-in-differences analysis was conducted in safety net and non-safety net hospitals participating in BPCI for medical episodes (BPCI hospitals) using data from 2011-2016 Medicare fee-for-service beneficiaries hospitalized for acute myocardial infarction, pneumonia, congestive heart failure, and chronic obstructive pulmonary disease. Hospital BPCI participation and safety net status. The primary outcome was postdischarge spending. Secondary outcomes included quality and post-acute care utilization measures. Our sample consisted of 803 safety net and 2263 non-safety net hospitals. Safety net hospitals were larger and located in areas with more low-income individuals than non-safety net hospitals. Among BPCI hospitals, safety net status was not associated with differential postdischarge spending (adjusted difference-in-differences [aDID], $40; 95% CI, -$254 to $335; P = .79) or quality (mortality, readmissions). However, BPCI safety net hospitals had differentially greater discharge to institutional post-acute care (aDID, 1.06 percentage points; 95% CI, 0.37-1.76; P = .003) and lower discharge home with home health (aDID, -1.15 percentage points; 95% CI, -1.73 to -0.58; P < .001) than BPCI non-safety net hospitals. Under medical condition bundles, safety net hospitals perform differently from other hospitals in terms of post-acute care utilization, but not spending. Policymakers could support safety net hospitals and consider safety net status when evaluating bundled payment programs.

Patient-reported Outcomes Among Vulnerable Populations in the Medicare Bundled Payments for Care Improvement Initiative.

The Centers for Medicare & Medicaid Services Bundled Payments for Care Improvement (BPCI) initiative tested whether episode-based payment models could reduce Medicare payments without harming quality. Among patients with vulnerabilities, BPCI appeared to effectively reduce payments while maintaining the quality of care. However, these findings could overlook potential adverse patient-reported outcomes in this population. We surveyed beneficiaries with 4 characteristics (Medicare-Medicaid dual eligibility; dementia; recent institutional care; or racial/ethnic minority) treated at BPCI-participating or comparison hospitals for congestive heart failure, sepsis, pneumonia, or major joint replacement of the lower extremity. We estimated risk-adjusted differences in patient-reported outcomes between BPCI and comparison respondents, stratified by clinical episode and vulnerable characteristic. Patient care experiences during episodes of care and patient-reported functional outcomes assessed roughly 90 days after hospitalization. We observed no differences in self-reported functional improvement between BPCI and comparison respondents with vulnerable characteristics. Patient-reported care experience was similar between BPCI and comparison respondents in 11 of 15 subgroups of clinical episode and vulnerability. BPCI respondents with congestive heart failure, sepsis, and pneumonia were less likely to indicate positive care experiences than comparison respondents for at least 1 subgroup with vulnerabilities. As implemented by hospitals, BPCI Model 2 was not associated with adverse effects on patient-reported functional status among beneficiaries who may be vulnerable to reductions in care. Hospitals participating in heart failure, sepsis or pneumonia bundled payment episodes should focus on patient care experience while implementing changes in care delivery.

Do Hospitals That Volunteer for Joint Replacement Bundled Payments Save More Money Than Those Required to Participate?

Research ObjectiveMedicare has used both voluntary and mandatory programs to engage hospitals in joint replacement bundles. Starting in 2013, hospitals voluntarily joined the Bundled Payments for Care Improvement (BPCI) program. In 2016, Medicare randomly assigned hospitals in 67 of 196 metropolitan statistical areas (MSAs) to mandatory bundled payments under the Comprehensive Care for Joint Replacement (CJR) program. Because the CJR mandate applied to both hospitals with and without prior experience in BPCI, Medicare created the unique opportunity to compare performance between hospitals that voluntarily self‐selected into bundled payments (i.e., chose to participate in BPCI prior to CJR) versus hospitals that did not (i.e., did not participate in BPCI prior to CJR).Study DesignOur study leveraged the randomized design of CJR and compared CJR MSAs to non‐CJR MSAs weighted by strata and using an intention‐to‐treat approach. We used 2011–2017 Medicare claims and generalized linear models with hospital fixed effects to conduct a difference‐in‐differences analysis evaluating patients in CJR‐mandated markets undergoing joint replacement at hospitals with BPCI experience (voluntary hospitals) versus without BPCI experience (mandatory hospitals) prior to CJR. Like prior work, our comparison group consisted of patients undergoing joint replacement at hospitals in non‐CJR markets without BPCI experience, i.e., hospitals without any joint replacement bundle experience (non‐participant hospitals). The study outcome was post‐discharge institutional spending. Standard errors were clustered by MSA.Population Studied1,568,567 Medicare fee‐for‐service beneficiaries hospitalized at 92 voluntary, 759 mandatory, and 911 non‐participant hospitals.Principal FindingsVoluntary hospitals tended to be larger than mandatory and non‐participant hospitals, and more likely to be non‐profit, teaching institutions. Voluntary hospitals also had higher financial margins and cared for lower proportions of Medicare/Medicaid dual‐eligible patients than other hospital types. In adjusted analyses, voluntary hospitals exhibited differentially lower post‐discharge institutional spending compared to non‐participants hospitals (adjusted difference‐in‐differences [aDID] ‐$539, 95% CI ‐$823 to ‐$255, p &lt; 0.001). Mandatory hospitals also had differentially lower post‐discharge institutional spending than non‐participant hospitals (aDID ‐$410, 95% CI ‐$645 to ‐$174, p = 0.001). Changes in post‐discharge institutional savings were not statistically significantly different between voluntary and mandatory hospitals (p = 0.34).ConclusionsHospitals that both voluntarily and involuntarily accepted bundled payments achieved joint replacement savings. We did not find evidence that voluntary participants achieved greater savings. These are the first empirical data for bundled payments – and value‐based payment reforms more generally – comparing financial performance between voluntary and mandatory participants.Implications for Policy or PracticeThis analysis has two major policy implications. First, it highlights the potential for policymakers to achieve payment reform goals by using both voluntary and mandatory programs, both of which possess benefits and drawbacks. By demonstrating that mandatory hospitals did not generate smaller savings than voluntary hospitals, our analysis also counters the idea that voluntary programs are more advantageous than mandatory ones because they can generate more savings. Second, it highlights that CJR effects were likely underestimated by Medicare and others given that BPCI predated and drove changes in joint replacement care prior to CJR.Primary Funding SourceNational Institutes of Health.

Association of Patient Outcomes With Bundled Payments Among Hospitalized Patients Attributed to Accountable Care Organizations

It is unknown how outcomes are affected when patients receive care under bundled payment and accountable care organization (ACO) programs simultaneously. To evaluate whether outcomes in the Medicare Bundled Payments for Care Improvement (BPCI) program differed depending on whether patients were attributed to ACOs in the Medicare Shared Savings Program. This cohort study was conducted using Medicare claims data from January 1, 2011, to September 30, 2016, and difference-in-differences analysis to compare episode outcomes for patients admitted to BPCI vs non-BPCI hospitals. Outcomes were stratified for patients who were and were not attributed to an ACO. Participants included Medicare fee-for-service beneficiaries receiving care for medical and surgical episodes at US hospitals. Data were analyzed between October 1, 2018, and June 10, 2021. Hospitalization for any of the 48 episodes (24 medical, 24 surgical) included in the BPCI at US hospitals participating in the BPCI for those episodes. The primary outcome was change in 90-day postdischarge institutional spending, and secondary outcomes included changes in quality and utilization. A total of 7 108 146 beneficiaries (mean [SD] age, 76.9 [12.2] years; 4 101 081 women [58%]) received care for medical episodes, and 3 675 962 beneficiaries (mean [SD] age, 74.8 [10.1] years; 2 074 921 women [56%]) received care for surgical episodes. Compared with patients who were not attributed to ACOs, the association between bundled payments and changes in postdischarge institutional spending was larger among patients attributed to ACOs (-$323 difference; 95% CI, -$607 to -$39; P = .03) for medical episodes, but not surgical episodes. Attribution to an ACO also increased the strength of the association between bundled payments and changes in 90-day readmissions for both medical episodes (-0.98 percentage point difference; 95% CI, -1.55 to -0.41; P = .001) and surgical episodes (-0.84 percentage point difference; 95% CI, -1.32 to -0.35; P = .001). In this cohort study, compared with inclusion in bundled payments alone, simultaneous inclusion in both ACOs and bundled payment programs was associated with lower institutional postacute care spending and readmissions for medical episodes and lower readmissions but not spending for surgical episodes. Receiving care under models such as ACOs may improve episode outcomes under bundled payments.

Bundled Payment Episodes Initiated by Physician Group Practices: Medicare Beneficiary Perceptions of Care Quality.

The Bundled Payments for Care Improvement (BPCI) initiative incentivizes participating providers to reduce total Medicare payments for an episode of care. However, there are concerns that reducing payments could reduce quality of care. To assess the association of BPCI with patient-reported functional status and care experiences. We surveyed a stratified random sample of Medicare beneficiaries with BPCI episodes attributed to participating physician group practices, and matched comparison beneficiaries, after hospitalization for one of the 18 highest volume clinical episodes. The sample included beneficiaries discharged from the hospital from February 2017 through September 2017. Beneficiaries were surveyed approximately 90 days after their hospital discharge. We estimated risk-adjusted differences between the BPCI and comparison groups, pooled across all 18 clinical episodes and separately for the five largest clinical episodes. Medicare beneficiaries with BPCI episodes (n=16,898, response rate=44.5%) and comparison beneficiaries hospitalized for similar conditions selected using coarsened exact matching (n=14,652, response rate=46.2%). Patient-reported functional status, care experiences, and overall satisfaction with recovery. Overall, we did not find differences between the BPCI and comparison respondents across seven measures of change in functional status or overall satisfaction with recovery. Both BPCI and comparison respondents reported generally positive care experiences, but BPCI respondents were less likely to report positive care experience for 3 of 8 measures (discharged at the right time, -1.2 percentage points (pp); appropriate level of care, -1.8 pp; preferences for post-discharge care taken into account, -0.9 pp; p<0.05 for all three measures). The proportion of respondents with favorable care experiences was smaller for BPCI than comparison respondents. However, we did not detect differences in self-reported change in functional status approximately 90 days after hospital discharge, indicating that differences in care experiences did not affect functional recovery.