Bundled Payments For Care Improvement Initiative Research Articles

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.

The Proportion of Marginalized Individuals in US Communities and Hospital Participation in Bundled Payments.

Hospitals have demonstrated the benefits of both voluntary and mandatory bundled payments for joint replacement surgery. However, given generalizability and disparities concerns, it is critical to understand the availability of care through bundled payments to historically marginalized groups, such as racial and ethnic minorities and individuals with lower socioeconomic status (SES). This cross-sectional analysis of 3880 US communities evaluated the relationship between the proportion of Black and Hispanic individuals (minority share) or Medicare/Medicaid dual-eligible individuals (low SES share) and community-level participation in Bundled Payments for Care Improvement initiative (BPCI) (being a BPCI community) and Comprehensive Care for Joint Replacement (CJR) model (being a CJR community). An increase from the lowest to highest quartile of minority share was not associated with differences in the probability of being a BPCI community (3.5 percentage point [pp] difference, 95% confidence interval [CI] -1.2% to 8.3%, P = 0.15), but was associated with a 16.1 pp higher probability of being a CJR community (95% CI 10.3% to 22.0%, P < 0.0001). An increase from the lowest to highest quartile of low SES share was associated with a 6.0 pp lower probability of being a BPCI community (95% CI -10.9% to -1.2%, P = 0.02) and 19.0 pp lower probability of being a CJR community (95% CI -24.9% to -13.0%, P < 0.0001). These findings highlight that the greater the proportion of lower SES individuals in a community, the lower the likelihood that its hospitals participated in either voluntary or mandatory bundled payments. Policymakers should consider community socioeconomic characteristics when designing participation mechanisms for future bundled payment programs.

100. Participation in bundled payments in spine surgery was associated with lower readmission rates: the one-year BPCI-Advanced experience

BACKGROUND CONTEXT The fundamental shift from volume to value in health care delivery has seen an increase in alternative payment models such as the Bundled Payments for Care Improvement Initiative (BPCI). The Centers for Medicaid and Medicare Services (CMS) implemented the most recent iteration of BPCI, BPCI Advanced (A) in 2018. BPCI-A is a retrospective payment model that provides a lump payment for a 90-day episode of care. BPCI-A for spine includes the diagnosis related groups (DRG) for cervical spine surgery (C_PSF, 471,472,473), lumbar spinal fusion (L_PSF, 459-460), and lumbar decompression/discectomy (Decomp, 518, 519, 520). In preparation for BPCI participation, our center instituted care delivery improvements based on CMS evaluation of our historical data that was utilized to determine eligibility for participation and from patient input. Care improvements included a weekly multidisciplinary stakeholder meeting and assignment of a full-time nurse care coordinator to cover BPCI-A patients from both the orthopedic/neurosurgery service lines. PURPOSE The purpose of the study was to determine whether patient outcomes, including length of stay, readmission rates and ED visits, changed following participation in BPCI compared with historical data. STUDY DESIGN/SETTING A retrospective and prospective claims data review of all Medicare patients into specified spine surgery DRGs. PATIENT SAMPLE This study included 358 retrospective patients, 63 prospective patients with minimum of 6 months of follow-up. OUTCOME MEASURES Emergency department (ED) utilization and readmission rates. METHODS As part of the BPCI-A application process, retrospective patient data from January 1, 2013 through November 30, 2017 were provided to CMS to determine bundle-specific target prices. BPCI-A began on October 1, 2019 and analyses included those patients whose participation ended by September 30, 2019 (BPCI group, n=63) and those included in the CMS historical review (pre-BPCI group, n=358). Patient and surgery characteristics including age, body mass index (BMI), gender, race, age-adjusted Charlson Comorbidity Index (CCI) scores, admission source, patient class, discharge disposition, length of stay (LOS), service line, surgeon and DRG were collected. Outcomes included ED visit utilization and readmissions. Descriptive statistics were performed and continuous variables were evaluated for normality using the Shapiro-Wilk test and through evaluation of histograms. Differences between pre-BPCI and BPCI groups were evaluated using Wilcoxon Rank Sum tests due to non-normal distributions, for continuous variables, and chi-square or exact tests for categorical variables, as appropriate. The odds of readmission or ED utilization were compared between BPCI and pre-BPCI groups using logistic regression. Analyses adjusted for potential confounders. RESULTS This study included 358 pre-BPCI and 63 BPCI patients (8 Decomp, 27 C_PSF, 30 L_PSF). We found no significant differences in age (median (IQR):70.3(9.2) vs 70.2(12.4) years), BMI (30.2(9.5) vs 31.4(9.1) kg/m2), LOS (4(3) vs 3(5) days), gender (51.7 vs 46.0% women), race (94.7 vs 96.8% white), MCC DRG (12.6 vs 17.5%) or discharge home (59.8% vs 61.9%, all p>0.05) in pre-BPCI vs BPCI patients, respectively. Patient class differences were noted (pre-BPCI:11.7 vs BPCI: 22.2% inpatient, p=0.024). Overall, the ED visit rates were similar in pre-BPCI (26.5%) vs BPCI patients (30.2%, p=0.551) though readmission rates were slightly lower following BPCI participation (15.9% vs 26.8%, p=0.065). There was also a trend for lower number of readmissions after BPCI (p=0.044) and analyses adjusted for service line and patient class revealed a greater odds of readmission in the pre-BPCI group vs BPCI (OR=2.53, 95%CI=1.14-5.58, p=0.022). Analyses stratified by bundles showed lower readmission rates in BPCI (8%) vs pre-BPCI group (27.5%, p=0.035) and a trend for lower readmission numbers (p=0.043) in the L_PSF bundle. However, no differences were noted in the Decomp or C_PSF bundles or for ED visits in any bundle (p>0.05). CONCLUSIONS Participation in spine bundled payments (BPCI-A) at a large academic medical center was associated with significantly lower readmission rates. Alignment of all stakeholder interests via a bundled payment framework may help mobilize additional health system resources to improve patients’ outcomes. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

The Implications of Aging Population Demographics on the Delivery of Primary Total Joint Arthroplasty in a Bundled Payment System.

The Centers for Medicare & Medicaid Services (CMS)'s Bundled Payments for Care Improvement (BPCI) program provides a set payment for the provision of primary total joint arthroplasty (TJA) care regardless of age and risk factors. Published literature indicates that the cost of care per episode of TJA increases with age. We examined the implication of this relationship and the effect of projected changes of age demographics on our center's BPCI experience. A retrospective review of prospectively collected data on 1,662 Medicare BPCI patients undergoing primary total knee arthroplasty (TKA) and total hip arthroplasty (THA) from 2013 to 2016 at a single orthopaedic institution was performed. The relationship between age and cost of care was first determined in our analysis of our BPCI experience. We then performed a cost analysis by age group with respect to our institution's profit or loss per episode of care. A forecast for shifting age demographics in our region, modeled by the U.S. Census Bureau's Federal-State Cooperative for Population Estimates (FSCPE) and Projections (FSCPP), was used to evaluate the financial implications for our BPCI program. Our institution sustains a significant loss of $1,934 (p < 0.001) per case for patients 85 to 99 years of age, which is offset by profits associated with treating patients in younger age groups. This age group (85 to 99 years of age) will double by the year 2040 in our region, whereas the youngest age group (65 to 69 years of age) is projected to marginally increase by 12%. The average cost of care per primary TJA will rise because of the predicted shifting age demographics, compounded by an estimated 3% inflation rate. Utilizing the current BPCI reimbursement rate, we project an inflection point of declining profits after the year 2030 with the given projections for our regional population. The regional population served by our institution is aging. This shift will lead to an increased cost of care and diminishing profits for TJA after 2030. The CMS's BPCI initiative and novel alternative payment models (APMs) should consider age as a modifier for reimbursement to incentivize care for the vulnerable and older age groups. The findings of the present study are clinically relevant for decision-making regarding the allocation of resources in the setting of an aging population.

Practice Makes Perfect: Bundled Payment Models for 90-Day Total Knee Arthroplasty Episodes

Commentary In this article, Schilling et al. provide a proper and elegant analysis of the variation in payments and resource utilization for total knee arthroplasty (TKA) immediately prior to the April 2016 implementation of the U.S. Comprehensive Care for Joint Replacement (CJR) bundled payment program, which was mandatory at the time of the study. Using the 100% sample of Medicare Part A claims data for this study, the authors included all elective unilateral primary TKAs performed in patients who were ≥65 years of age between January 1, 2014, and December 31, 2016. One methodological concern is a lack of description of the methods used to handle missing data, negative costs, and zero costs that exist with claims data. The inclusion of such data could impact the results, even with this large sample size of >700,000 TKAs. Regardless, this article contributes very good information to the body of knowledge of alternate payment models, and the authors even suggest that the risk-adjusted model could be adopted by hospitals to benchmark their performance in such models. However, questions remain about the degree to which the CJR program was responsible for the results and whether providers will successfully sustain these improvements. Schilling et al. illustrate that resource utilization, measured by Medicare Part A payments, length of hospital stay, readmissions, and inpatient post-acute care utilization, for Medicare patients undergoing TKA decreased nationally from 2014 to 2016. Therefore, these trends in decreased spending and resource utilization began prior to April 2016 when the CJR model was implemented. The CJR model was implemented in a time when other value-based initiatives were impacting TKA care redesign, particularly the Bundled Payments for Care Improvement (BPCI) program, which began in 2013 and broadly influenced utilization rates in participating markets1,2. Furthermore, the early results of BPCI Advanced suggest that retrospective shared savings models such as CJR and BPCI create a floor in market pricing, after which incentives become too low to elicit participation1-3. Although the CJR model participation was initially mandatory, voluntary participation continues through December 2020. Early evaluations have suggested that the CJR model was somewhat successful. Barnett et al. reported a modest 3% decrease in spending with no significant changes in postoperative complications4. It is reasonable to posit that the gradual transition from a fee-for-service payment model to a value-based care model impacted the decrease that Schilling et al. report. Although payment reform has been underway since 1983, the first bundled payment model for orthopaedics began in 2009 with the Acute Care Episode (ACE) program5. The testing of this model was narrow in scope, with just 5 hospitals participating5. In 2013, the Medicare BPCI initiative began, with >1,200 participating entities in July 20183. The BPCI initiative substantially broadened the scope to include physician groups and post-acute facilities, in addition to hospitals. Most participants chose a retrospective shared savings model that focused on reducing post-acute utilization, which drove down the mean episode costs in participating markets, without degradation in outcomes. This had 2 important effects: (1) early participants developed best practices for the BPCI program that the CJR program participants were able to replicate to perform well with respect to all shared savings, and (2) strong performance in the BPCI program lowered the mean target spending for Medicare nationally for this procedure, thus reducing the opportunity for further shared savings in subsequent programs in a given market. There was an initial 16% decrease in participants just before the March 1, 2019, deadline to enroll in the BPCI Advanced program6. Presumably, this is because institutions and providers cannot lower costs and readmissions sufficiently more to warrant participation. The time periods of the BPCI and CJR programs overlapped and both included Medicare patients2,3. Therefore, the trend in the improved value of TKA illustrated by Schilling et al. includes the successful impacts of the BPCI program. The CJR program began in April 2016 and, at the time, it was mandatory for total joint replacement unless providers were participating in the BPCI program, which began in 20132,3. The design of the CJR bundled payment model was informed by the BPCI bundled payment model; however, physician groups could be episode initiators with the BPCI program but not with the CJR program. Regardless, the effects of the BPCI model are present in the data used in this study. This does not negate the importance and utility of this study by Schilling et al. to serve as a benchmark for future bundled payment models that will include procedure-based bundles.

Risk Adjustment is Necessary for Bundled TKA Patients

With health care costs in the United States rising at an exponential rate, providers, payers, and policymakers have all sought to develop alternative payment models to seek value in care. For procedures such as total knee arthroplasty (TKA), which accounts for Medicare’s largest inpatient expenditure, the Centers for Medicare and Medicaid Services (CMS) and private insurers have introduced bundled payment programs aimed at reducing cost and improving the quality of patient care. Although traditionally, TKA has been reimbursed by Medicare through a fee-for-service model rewarding quantity of services provided versus quality of service, the Bundled Payments for Care Improvement Initiative (BPCI) and the Comprehensive Care for Joint Replacement Model (CJR) seek to align incentives among providers and health care systems by providing a single payment for all services rendered during an episode of care for TKA. Although early published data from these programs suggests substantial cost savings to CMS without an increase in complications, concerns exist regarding access to care for patients who may utilize more resources in an episode of care. Without appropriate risk adjustment, providers are disincentivize to perform TKA on patients at risk for complications and readmissions. Alternative payment models have reduced costs and improved patient outcomes by incentivizing providers to optimize modifiable risk factors before elective TKA, including glycemic control, smoking, body mass index, and malnutrition. Several studies, however, have shown that nonmodifiable risk factors including advanced age, lower socioeconomic status, and several medical and orthopaedic comorbidities are costlier to the health care system following TKA. These patients may face difficulty obtaining quality arthroplasty care with the expansion of bundled payment programs. In order to protect access to care, alternative payment models should not penalize surgeons and hospitals for caring for complex patients and instead provide appropriate, fair, risk-adjusted payments.

Bundled Payment Initiative for Hip Fracture Arthroplasty Patients: One Institution's Experience.

To analyze the effectiveness of a Bundled Payments for Care Improvement (BPCI) initiative at a large urban medical center for hip fracture patients included in the bundle payment program with respect to improving patient outcomes and reducing cost. Retrospective cohort. Single Academic Institution. Patients discharged with the diagnosis-related group codes 469-470 performed for hip fractures between July 2011 and September 2014 were evaluated. A BPCI initiative focused on optimizing care coordination, patient education, expectations, and minimizing postacute facility and resource utilization was initiated in October 2013. Patient outcomes before the introduction of the BPCI initiative were compared with those who participated in the initiative. Application of BPCI principles. Length of stay, location of discharge, readmission within 90 days, and 90-day episode of care costs. Sixty-one patients received care before the initiative, and 44 patients were treated with the initiative. The mean length of stay decreased from 6.8 to 5.3 days and the percentage of patients discharged home increased by nearly 10% with the introduction of the BPCI initiative (6.6% vs. 15.9%). There was a 13.1% reduction in total 90-day episode of care cost ($57,546 vs. $49,993, P = 0.210) on introduction of the initiative. There was no significant difference in readmission rate between the 2 cohorts. This study demonstrates the success of one such program for hip fracture arthroplasty patients aimed at care coordination and minimizing postacute hospitalization facility care both with respect to improved patient outcomes and substantial cost reduction. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Association of Hospital Participation in a Medicare Bundled Payment Program With Volume and Case Mix of Lower Extremity Joint Replacement Episodes

Medicare's Bundled Payments for Care Improvement (BPCI) initiative for lower extremity joint replacement (LEJR) surgery has been associated with a reduction in episode spending and stable-to-improved quality. However, BPCI may create unintended effects by prompting participating hospitals to increase the overall volume of episodes paid for by Medicare, which could potentially eliminate program-related savings or prompt them to shift case mix to lower-risk patients. To evaluate whether hospital BPCI participation for LEJR was associated with changes in overall volume and case mix. Observational study using Medicare claims data and a difference-in-differences method to compare 131 markets (hospital referral regions) with at least 1 BPCI participant hospital (n = 322) and 175 markets with no participating hospitals (n = 1340), accounting for 580 043 Medicare beneficiaries treated before (January 2011-September 2013) and 462 161 after (October 2013-December 2015) establishing the BPCI initiative. Hospital-level case-mix changes were assessed by comparing 265 participating hospitals with a 1:1 propensity-matched set of nonparticipating hospitals from non-BPCI markets. Hospital BPCI participation. Changes in market-level LEJR volume in the before vs after BPCI periods and changes in hospital-level case mix based on demographic, socioeconomic, clinical, and utilization factors. Among the 1 717 243 Medicare beneficiaries who underwent LEJR (mean age, 75 years; 64% women; and 95% nonblack race/ethnicity), BPCI participation was not significantly associated with a change in overall market-level volume. The mean quarterly market volume in non-BPCI markets increased 3.8% from 3.8 episodes per 1000 beneficiaries before BPCI to 3.9 episodes per 1000 beneficiaries after BPCI was launched. For BPCI markets, the mean quarterly market volume increased 4.4% from 3.6 episodes per 1000 beneficiaries before BPCI to 3.8 episodes per 1000 beneficiaries after BPCI was launched. The adjusted difference-in-differences estimate between the market types was 0.32% (95% CI, -0.06% to 0.69%; P = .10). Among 20 demographic, socioeconomic, clinical, and utilization factors, BPCI participation was associated with differential changes in hospital-level case mix for only 1 factor, prior skilled nursing facility use (adjusted difference-in-differences estimate, -0.53%; 95% CI, -0.96% to -0.10%; P = .01) in BPCI vs non-BPCI markets. In this observational study of Medicare beneficiaries who underwent LEJR, hospital participation in Bundled Payments for Care Improvement was not associated with changes in market-level lower extremity joint replacement volume and largely was not associated with changes in hospital case mix. These findings may provide reassurance regarding 2 potential unintended effects associated with bundled payments for LEJR.

Effectiveness of a Model Bundle Payment Initiative for Femur Fracture Patients.

To analyze the effectiveness of a Bundled Payment for Care Improvement (BPCI) initiative for patients who would be included in a future potential Surgical Hip and Femur Fracture Treatment bundle. Retrospective cohort. Single Academic Institution. Patients discharged with operative fixation of a hip or femur fracture (Diagnosis-Related Group codes 480-482) between January 2015 and October 2016 were included. A BPCI initiative based on an established program for BPCI total joint arthroplasty was initiated for patients with hip and femur fractures in January 2016. Patients were divided into nonbundle (care before initiative) and bundle (care with initiative) cohorts. Application of BPCI principles. Length of stay, location of discharge, and readmissions. One hundred sixteen patients participated in the "institutional bundle," and 126 received care before the initiative. There was a trend toward decreased mean length of stay (7.3 ± 6.3 days vs. 6.8 ± 4.0 days, P = 0.457) and decreased readmission within 90 days (22.2% vs. 18.1%, P = 0.426). The number of patients discharged home doubled (30.2% vs. 14.3%, P = 0.008). There was no difference in readmission rates in bundle versus nonbundle patients based on discharged home status; however, bundle patients discharged to a skilled nursing facility trended toward less readmissions than nonbundle patients discharged to a skilled nursing facility (37.3% vs. 50.6%, P = 0.402). Mean episode cost reduction due to initiative was estimated to be $6450 using Medicare reimbursement data. This study demonstrates the potential success of a BPCI initiative at 1 institution in decreasing postacute care facility utilization and cost of care when used for a hip and femur fracture population. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

In-House Cardiology Consultation Reduces Readmission Rates and Costs for Patients in Skilled Nursing Facilities: 2 Years’ Experience in the Heart Failure Bundle Payment Care Improvement Initiative

Background Heart failure (HF) patients admitted to skilled nursing facilities (SNFs) are vulnerable to poor outcomes. CMS developed the Bundled Payments for Care Improvement Initiative (BPCI) which provides participating providers shared savings based on costs for 90-day episodes of care with the purpose of improving quality and cost-effectiveness. Greater availability of clinical staff has shown promise in improving outcomes for SNF patients. The effect of cardiology consultation for SNF patients with HF has not been evaluated. This study evaluates the impact of a SNF-based cardiologist-led HF program on 90-day readmission rate and resource utilization. Methods We performed a retrospective analysis using Medicare claims data of BPCI-enrolled HF patients admitted to St. Joseph's Center (SJC), a Genesis Healthcare SNF with a cardiologist-led HF program. Data were collected from October 2015 to September 2017. Readmission rates and cost savings versus CMS-determined cost targets were compared between SJC and 31 other enrolled SNFs, 24 of which had no HF program, 7 of which had standard programs composed of a multidisciplinary team of dietary, rehabilitation, social work and clinical staff. The SJC program additionally instructed staff to request cardiac consultation for patients with unstable vital signs, refractory volume overload or symptoms, or cardiac limitations to rehabilitative therapy. Cardiology rounds were conducted weekly and management was provided in the context of achieving subacute rehabilitation goals, clinical stability, and preparing for community discharge. The cardiologist identified and alerted staff to patients deemed high risk for readmission, and multidisciplinary monitoring and management for those patients was intensified. Results There were 602 total HF episodes in the 24-month evaluation period. Seventeen patients were admitted to SJC; 218 patients to a facility with a HF program; and 367 patients to a facility without a HF program. The case mix complexity at SJC included a higher percentage of patients with major complications and comorbid conditions (71% vs 60% for all other SNFs and 64% for SNFs with HF programs). More than 50% of patients at SJC prompted specialty consultation. Compared to other facilities, the percentage of SJC patients readmitted in the 90-day post HF hospitalization period was significantly lower (23.5% vs 43.4% (p = .052) for all other SNFs; and 48.2% (p = .025) for SNFs with a non-cardiologist based HF program). SJC achieved a higher margin of cost savings compared to facilities that did not have a consulting cardiologist (39% vs 15%). Conclusion Patient-centered cardiology consultation for high risk HF patients may effectively reduce re-hospitalizations and resource utilization within SNFs. These results identify a potential gap in care for this vulnerable cohort of HF patients and suggest that incorporating a cardiologist into the management team may impact outcomes.

Bundled Payments for Care Improvement in the Private Sector: A Win for Everyone

BackgroundTo help slow the rising costs associated with total joint arthroplasty (TJA), the Centers for Medicare and Medicaid Services introduced the Bundled Payments for Care Improvement (BPCI) initiative. The purpose of this study is to report our 1-year experience with BPCI in our 2 arthroplasty surgeon private practice. MethodsIn this series, a historical baseline group is compared with our first year under BPCI. We reviewed the cohorts with respect to hospital length of stay (LOS), readmission rates, discharge disposition, postacute care LOS, and overall savings on a per episode basis. ResultsThe baseline group included 582 episodes from July 2009 to June 2012. The BPCI study group included 332 episodes from July 2015 to September 2016. We witnessed a substantial learning curve over the course of our involvement in the initiative. The total reduction in cost per episode for TJA was 20.0% (P = .10). Hospital LOS decreased from 4.9 to 3.5 days (P = .02). All-cause 90-day readmission rates decreased from 14.5% to 8.2% (P = .0078). Overall, discharges to home increased from 11.6% to 49.8% (P = .005). ConclusionOur small, private, 2 arthroplasty surgeon orthopedic practice has shown improvement in postoperative management for TJA patients in 1 year under the BPCI initiative, with increased discharges to home, decreased skilled nursing admissions, days in skilled nursing, and overall readmissions. Because BPCI includes fracture care arthroplasty, the model could be made more equitable if these patients were reimbursed a rate commensurate with their increased costs and risks.

Bundled Payments for Care Improvement: Preparing for the Medical Diagnosis-Related Groups.

BACKGROUNDThe Centers for Medicare and Medicaid Services Innovation Center introduced the Bundled Payments for Care Improvement (BPCI) initiative in 2011 as 1 strategy to encourage healthcare organizations and clinicians to improve healthcare delivery for patients, both when they are in the hospital and after they are discharged. Mercy Health Saint Mary’s, a large urban academic medical center, engaged in BPCI primarily with a group of medical diagnosis-related groups (DRGs).OBJECTIVESIn this article, we describe our experience creating a system of response for the diverse people and diagnoses that fall into the medical DRG bundles and specifically identify organizational factors for enabling successful implementation of bundled payments.RESULTSOur experience suggests that interprofessional collaboration enabled program success.CONCLUSIONSAlthough still in its early phases, observations from our program’s strategies and tactics may provide potential insights for organizations considering engagement in the BPCI initiative.

Results of a Medicare Bundled Payments for Care Improvement Initiative for Chronic Obstructive Pulmonary Disease Readmissions.

Approximately 20% of Medicare beneficiaries hospitalized for acute exacerbations of chronic obstructive pulmonary disease (COPD) are readmitted within 30 days of discharge. In addition to implementing penalties for excess readmissions, the U.S. Centers for Medicare and Medicaid Services has developed Bundled Payments for Care Improvement (BPCI) initiatives to improve outcomes and control costs. To evaluate whether a comprehensive COPD multidisciplinary intervention focusing on inpatient, transitional, and outpatient care as part of our institution's BPCI participation would reduce 30-day all-cause readmission rates for COPD exacerbations and reduce overall costs. We performed a pre-postintervention study comparing all-cause readmissions and costs after index hospitalization for Medicare-only patients with acute exacerbation of COPD. The primary outcome was the difference in 30-day all-cause readmission rate compared with historical control subjects; secondary outcomes included the 90-day all-cause readmission rate and also health care costs compared with BPCI target prices. Seventy-eight consecutive Medicare patients were prospectively enrolled in the BPCI intervention in 2014 and compared with 109 patients in the historical group from 2012. Patients in BPCI were more likely to receive regular follow-up phone calls, pneumococcal and influenza vaccines, home health care, durable medical equipment, and pulmonary rehabilitation, and to attend pulmonary clinic. There was no difference in all-cause readmission rates at 30 days (BPCI, 12 events [15.4%] vs. non-BPCI, 19 events [17.4%]; P = 0.711), and 90 days (21 [26.9%] vs. 37 [33.9%]; P = 0.306). Compared with BPCI target prices, we incurred 4.3% lower 90-day costs before accounting for significant investment from the health system. A Medicare BPCI intervention did not reduce 30-day all-cause readmission rates or overall costs after hospitalization for acute exacerbation of COPD. Although additional studies enrolling larger numbers of patients at multiple centers may demonstrate the efficacy of our BPCI initiative for COPD readmissions, this is unlikely to be cost effective at any single center.

BPCI: Everyone Wins, Including the Patient

BackgroundAlternative payment models are becoming increasingly more common with the rising cost of the US health care. Bundled payment programs for elective hip and knee arthroplasty have shown promising results by improved outcomes and significant cost reduction. MethodsAll consecutive total joint arthroplasty with diagnosis-related group (DRG) 469/470 were included in this study. And 1427 episodes from 2009 to 2012 were defined as the baseline group; 461 episodes from October 2013 to September 2014 were defined as the Bundled Payments for Care Improvement (BPCI) group. ResultsBPCI group had a 14% reduction in cost per episode. The average length of stay decreased from 3.81 to 2.57 days. All-cause readmissions within 90 days of surgery decreased from 16% to 10%. The average cost of readmission decreased by 23%. Net Centers for Medicare and Medicaid Services (CMS) reconciliation payment for BPCI initiative participation was $1,012,962.79 for this 12-month study. ConclusionOur participation in the 2013-2014 CMS BPCI initiative for DRG 469/470 led to decreased readmissions and significant cost savings. In this study, minimizing hospital length of stay and discharging patients to home were the most effective strategies to achieve these outcomes.

Association Between Hospital Participation in a Medicare Bundled Payment Initiative and Payments and Quality Outcomes for Lower Extremity Joint Replacement Episodes

Bundled Payments for Care Improvement (BPCI) is a voluntary initiative of the Centers for Medicare & Medicaid Services to test the effect of holding an entity accountable for all services provided during an episode of care on episode payments and quality of care. To evaluate whether BPCI was associated with a greater reduction in Medicare payments without loss of quality of care for lower extremity joint (primarily hip and knee) replacement episodes initiated in BPCI-participating hospitals that are accountable for total episode payments (for the hospitalization and Medicare-covered services during the 90 days after discharge). A difference-in-differences approach estimated the differential change in outcomes for Medicare fee-for-service beneficiaries who had a lower extremity joint replacement at a BPCI-participating hospital between the baseline (October 2011 through September 2012) and intervention (October 2013 through June 2015) periods and beneficiaries with the same surgical procedure at matched comparison hospitals. Lower extremity joint replacement at a BPCI-participating hospital. Standardized Medicare-allowed payments (Medicare payments), utilization, and quality (unplanned readmissions, emergency department visits, and mortality) during hospitalization and the 90-day postdischarge period. There were 29 441 lower extremity joint replacement episodes in the baseline period and 31 700 in the intervention period (mean [SD] age, 74.1 [8.89] years; 65.2% women) at 176 BPCI-participating hospitals, compared with 29 440 episodes in the baseline period (768 hospitals) and 31 696 episodes in the intervention period (841 hospitals) (mean [SD] age, 74.1 [8.92] years; 64.9% women) at matched comparison hospitals. The BPCI mean Medicare episode payments were $30 551 (95% CI, $30 201 to $30 901) in the baseline period and declined by $3286 to $27 265 (95% CI, $26 838 to $27 692) in the intervention period. The comparison mean Medicare episode payments were $30 057 (95% CI, $29 765 to $30 350) in the baseline period and declined by $2119 to $27 938 (95% CI, $27 639 to $28 237). The mean Medicare episode payments declined by an estimated $1166 more (95% CI, -$1634 to -$699; P < .001) for BPCI episodes than for comparison episodes, primarily due to reduced use of institutional postacute care. There were no statistical differences in the claims-based quality measures, which included 30-day unplanned readmissions (-0.1%; 95% CI, -0.6% to 0.4%), 90-day unplanned readmissions (-0.4%; 95% CI, -1.1% to 0.3%), 30-day emergency department visits (-0.1%; 95% CI, -0.7% to 0.5%), 90-day emergency department visits (0.2%; 95% CI, -0.6% to 1.0%), 30-day postdischarge mortality (-0.1%; 95% CI, -0.3% to 0.2%), and 90-day postdischarge mortality (-0.0%; 95% CI, -0.3% to 0.3%). In the first 21 months of the BPCI initiative, Medicare payments declined more for lower extremity joint replacement episodes provided in BPCI-participating hospitals than for those provided in comparison hospitals, without a significant change in quality outcomes. Further studies are needed to assess longer-term follow-up as well as patterns for other types of clinical care.

Alternative Reimbursement Models: Bundled Payment and Beyond: AOA Critical Issues.

The Bundled Payments for Care Improvement (BPCI) initiative was begun in January 2013 by the U.S. Centers for Medicare & Medicaid Services (CMS) through its Innovation Center authority, which was created by the U.S. Patient Protection and Affordable Care Act (PPACA). The BPCI program seeks to improve health-care delivery and to ultimately reduce costs by allowing providers to enter into prenegotiated payment arrangements that include financial and performance accountability for a clinical episode in which a risk-and-reward calculus must be determined. BPCI is a contemporary 3-year experiment designed to test the applicability of episode-based payment models as a viable strategy to transform the CMS payment methodology while improving health outcomes. A summary of the 4 models being evaluated in the BPCI initiative is presented in addition to the awardee types and the number of awardees in each model. Data from one of the BPCI-designated pilot sites demonstrate that strategies do exist for successful implementation of an alternative payment model by keeping patients first while simultaneously improving coordination, alignment of care, and quality and reducing cost. Providers will need to embrace change and their areas of opportunity to gain a competitive advantage. Health-care providers, including orthopaedic surgeons, health-care professionals at post-acute care institutions, and product suppliers, all have a role in determining the strategies for success. Open dialogue between CMS and awardees should be encouraged to arrive at a solution that provides opportunity for gainsharing, as this program continues to gain traction and to evolve.

Cardiology and accountable care.

Cardiovascular disease is the leading cause of death in the United States and accounts for ≈17% of national health expenditures and 30% of Medicare spending.1 Among physician groups and professional societies, cardiologists have been among those leading efforts to create evidence-based guidelines and to measure quality of care. In the post-health reform era, national efforts have expanded beyond quality to include innovative delivery models, such as the patient-centered medical home (PCMH), the medical neighborhood, and accountable care organizations (ACOs). This next generation of care models and the payment strategies that support them incentivize efficiency, patient-centeredness, and care coordination with an emphasis on primary care. We propose strategies for cardiologists to create collaborative opportunities within these new models drawing from examples from around the country within the context of a framework developed by the American College of Physicians.2 Pursuing these approaches or others along similar lines will enable cardiologists to lead and to be active participants in shaping delivery system transformation. These innovative delivery models share similar features. The PCMH is a model of care that emphasizes additional support for primary care providers within a patient-centered team, whereas a medical neighborhood represents a broader collection of primary care doctors, specialists such as cardiologists, hospitals, and other stakeholders within a region that seek to reduce fragmented care by sharing accountability.2,3 The ACO, too, is a broader care delivery arrangement, but in this case, groups of providers are accountable for the quality, cost, and overall care of a particular population, typically defined by the payer. In the Medicare Shared Savings Program (MSSP), an ACO model for Medicare beneficiaries, the ACO can capture shared savings if it reduces its healthcare expenditures and meets certain quality performance standards, nearly half of which are related to cardiovascular disease.4 Within the …