Payments For Care Improvement Initiative Research Articles

Sacubitril/Valsartan in Medicare Alternative Payment Models

Optimizing utilization of sacubitril/valsartan for treatment of heart failure could improve provider performance in the Bundled Payments for Care Improvement initiative and the Medicare Shared Savings Program.

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.

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.

Hospital to Home Transition for Patients With Stroke Under Bundled Payments

Bundled payments are a promising alternative payment model for reducing costs and improving the coordination of postacute stroke care, yet there is limited evidence supporting the effectiveness of bundled payments for stroke. This may be due to the lack of effective strategies to address the complex needs of stroke survivors. In this article, we describe COMprehensive Post-Acute Stroke Services (COMPASS), a comprehensive transitional care intervention focused on discharge from the acute care setting to home. COMPASS may serve as a potential care redesign strategy under bundled payments for stroke, such as the Centers for Medicare & Medicaid Innovation Bundled Payment for Care Improvement Initiative. The COMPASS care model is aligned with the incentive structures and essential components of bundled payments in terms of care coordination, patient assessment, patient and family involvement, and continuity of care. Ongoing evaluation will inform the design of incorporating COMPASS-like transitional care interventions into a stroke bundle.

Considerations for Payment Bundling in Cleft Care.

Since the introduction of the Bundled Payments for Care Improvement initiative, progress has been made in piloting bundled payment models to improve care coordination and curtail health care expenditures. In light of improvements in patient outcomes and the concomitant reduction in health care spending for certain high-volume and high-cost procedures, such as total joint arthroplasty and breast reconstruction, the authors discuss theoretical considerations for bundling payments for the care of patients with orofacial clefts. The reasons for and against adopting such a payment model to consolidate cleft care, as well as the challenges to implementation, are discussed. The authors purport that bundled payments can centralize components of cleft care and offer financial incentives to reduce costs and improve the value of care provided, but that risk adjustment based on the longitudinal nature of care, disease severity, etiologic heterogeneity, variations in outcomes reporting, and varying definitions of the episode of care remain significant barriers to implementation.

Robotic total knee arthroplasty: A missed opportunity for cost savings in Bundled Payment for Care Improvement initiatives?

BackgroundThe use of robotic total knee arthroplasty has become increasingly prevalent. Proponents of robotic total knee arthroplasty tout its potential to not only improve outcomes, but also to reduce costs compared with traditional total knee arthroplasty. Despite its potential to deliver on the value proposition, whether robotic total knee arthroplasty has led to improved outcomes and cost savings within Medicare’s Bundled Payment for Care Improvement initiative remains unexplored. MethodsMedicare beneficiaries who underwent total knee arthroplasty designated under Medicare severity diagnosis related group 469 or 470 in the year 2017 were identified using the 100% Medicare Inpatient Standard Analytic Files. Hospitals participating in the Bundled Payment for Care Improvement were identified using the Bundled Payment for Care Improvement analytic file. We calculated risk-adjusted, price-standardized payments for the surgical episode from admission through 90-days postdischarge. Outcomes, utilization, and spending were assessed relative to variation between robotic and traditional total knee arthroplasty. ResultsOverall, 198,371 patients underwent total knee arthroplasty (traditional total knee arthroplasty: n= 194,020, 97.8% versus robotic total knee arthroplasty: n = 4,351, 2.2%). Among the 3,272 hospitals that performed total knee arthroplasty, only 300 (9.3%) performed robotic total knee arthroplasty. Among the 183 participating in the Bundled Payment for Care Improvement, only 40 (19%) hospitals performed robotic total knee arthroplasty. Risk-adjusted 90-day episode spending was $14,263 (95% confidence interval $14,231–$14,294) among patients who underwent traditional total knee arthroplasty versus $13,676 (95% confidence interval $13,467–$13,885) among patients who had robotic total knee arthroplasty. Patients who underwent robotic total knee arthroplasty had a shorter length of stay (traditional total knee arthroplasty: 2.3 days, 95% confidence interval: 2.3–2.3 versus robotic total knee arthroplasty: 1.9 days, 95% confidence interval: 1.9–2.0), as well as a lower incidence of complications (traditional total knee arthroplasty: 3.3%, 95% confidence interval: 3.2–3.3 versus robotic total knee arthroplasty: 2.7%, 95% confidence interval: 2.3–3.1). Of note, patients who underwent robotic total knee arthroplasty were less often discharged to a postacute care facility than patients who underwent traditional total knee arthroplasty (traditional total knee arthroplasty: 32.4%, 95% confidence interval: 32.3–32.5 versus robotic total knee arthroplasty: 16.8%, 95% confidence interval 16.1–17.6). Both Bundled Payment for Care Improvement and non-Bundled Payment for Care Improvement hospitals with greater than 50% robotic total knee arthroplasty utilization had lower spending per episode of care versus spending at hospitals with less than 50% robotic total knee arthroplasty utilization. ConclusionOverall 90-day episode spending for robotic total knee arthroplasty was lower than traditional total knee arthroplasty (Δ $–587, 95% confidence interval: $–798 to $–375). The decrease in spending was attributable to shorter length of stay, fewer complications, as well as lower utilization of postacute care facility. The cost savings associated with robotic total knee arthroplasty was only realized when robotic total knee arthroplasty volume surpassed 50% of all total knee arthroplasty volume. Hospitals participating in the Bundled Payment for Care Improvement may experience cost-saving with increased utilization of robotic total knee arthroplasty.

Results of Care Redesign for Joint Arthroplasty in the BPCI Program in an Independent Physician-Owned Orthopedic Group.

BackgroundThe Bundled Payment for Care Improvement initiative is a program designed by Center for Medicare and Medicaid Services in an attempt to increase the value of care delivered to Medicare recipients by rewarding providers who can deliver more cost-efficient, high-value care. This article reports the results of a coordinated care redesign program in an independent, medium-sized private-practice orthopedic group.MethodsA committee of stakeholders worked to redesign care protocols for patients receiving upper and lower joint replacement procedures. These protocols included preoperative, intraoperative, and postoperative care. Baseline metrics for post-acute care and readmissions were compared to the same metrics after initiating care redesign.ResultsIncidence of discharge to inpatient facilities decreased as did length of stay at these facilities. Home health utilization and readmission rates were lowered. Average cost of the 90-day episodes decreased to a statistically significant degree.ConclusionsThese initial results indicate that coordinated care redesign in the private practice setting can yield higher value care with decreased utilization of high-cost care, particularly in the post-acute period.

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.

Target Price Adjustment for Hip Fractures Is Not Sufficient in the Bundled Payments for Care Improvement Initiative

BackgroundUnder the Bundled Payments for Care Improvement (BPCI) initiative, the Centers for Medicare and Medicaid Services (CMS) adjusts the target price for total hip arthroplasty (THA) based upon the historical proportion of fracture cases. Concerns exist that hospitals that care for hip fracture patients may be penalized in BPCI. The purpose of this study is to compare the episode-of-care (EOC) costs of hip fracture patients to elective THA patients. MethodsWe reviewed a consecutive series of 4096 THA patients from 2015 to 2018. Patients were grouped into elective THA (n = 3686), fracture THA (n = 176), and hemiarthroplasty (n = 274). Using CMS claims data, we compared EOC costs, postacute care costs, and performance against the target price between the groups. To control for confounding variables, we performed a multivariate analysis to identify the effect of hip fracture diagnosis on costs. ResultsElective THA patients had lower EOC ($18,200 vs $42,605 vs $38,371; P < .001) and postacute care costs ($4477 vs $28,093 vs $23,217; P < .001) than both hemiarthroplasty and THA for fracture. Patients undergoing arthroplasty for fracture lost an average of $23,122 (vs $1648 profit for elective THA; P < .001) with 91% of cases exceeding the target price (vs 20% for elective THA; P < .001). In multivariate analysis, patients undergoing arthroplasty for fracture had higher EOC costs by $19,492 (P < .001). ConclusionPatients undergoing arthroplasty for fracture cost over twice as much as elective THA patients. CMS should change their methodology or exclude fracture patients from BPCI, particularly during the COVID-19 pandemic.

Spending and quality after three years of Medicare’s bundled payments for medical conditions: quasi-experimental difference-in-differences study

ObjectiveTo evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during...

The Impact Of Bundled Payment On Health Care Spending, Utilization, And Quality: A Systematic Review.

The Centers for Medicare and Medicaid Services (CMS) has promoted bundled payment programs nationwide as one of its flagship value-based payment reforms. Under bundled payment, providers assume accountability for the quality and costs of care delivered during an episode of care. We performed a systematic review of the impact of three CMS bundled payment programs on spending, utilization, and quality outcomes. The three programs were the Acute Care Episode Demonstration, the voluntary Bundled Payments for Care Improvement initiative, and the mandatory Comprehensive Care for Joint Replacement model. Twenty studies that we identified through search and screening processes showed that bundled payment maintains or improves quality while lowering costs for lower extremity joint replacement, but not for other conditions or procedures. Our review also suggests that policy makers should account for patient-level heterogeneity and include risk stratification for specific conditions in emerging bundled payment programs.

Comparison of Payment Margins Between the Bundled Payments for Care Improvement Initiative and the Comprehensive Care for Joint Replacement Model Shows a Marked Reduction for a Successful Program.

The Comprehensive Care for Joint Replacement (CJR) model was implemented to address the 2 most commonly billed inpatient surgical procedures, total hip arthroplasty and total knee arthroplasty. The primary purpose of this study was to review the economic implications of 1 institution's mandatory involvement in the CJR in comparison with prior involvement in the Bundled Payments for Care Improvement (BPCI) initiative. The mean cost per episode of care was calculated using our institution's historical data. The target prices, projected savings or losses per episode of care, and projected annual savings for both BPCI and CJR were established and were comparatively analyzed. The CJR target prices will decrease in comparison with BPCI target prices by 24.0% for Medicare Severity-Diagnosis Related Group (MS-DRG) 469 without fracture, 22.8% for MS-DRG 469 with fracture, 26.1% for MS-DRG 470 without fracture, and 27.7% for MS-DRG 470 with fracture, resulting in a reduction in savings per episode of care by 92.8% for MS-DRG 469 without fracture, 166.0% for MS-DRG 469 with fracture, 94.9% for MS-DRG 470 without fracture, and 61.7% for MS-DRG 470 with fracture. Our institution's projected annual savings under CJR will decrease by 83.3%. These results suggest that the margin for savings in the CJR will be substantially reduced compared with the margin for savings in the BPCI. In hospitals that had previously devoted resources, these will have far less impact in the CJR, and hospitals new to the CJR that have not made these investments previously will require even greater resources for developing cost reduction and quality control strategies to remain financially solvent. Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

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.

Association of Medicare's Bundled Payments for Care Improvement initiative with patient-reported outcomes.

To determine whether the Bundled Payments for Care Improvement (BPCI) initiative affected patient-reported measures of quality. Surveys of Medicare fee-for-service beneficiaries discharged from acute care hospitals participating in BPCI Model 2 and comparison hospitals between October 2014 and June 2017. Variables from Medicare administrative data and the Provider of Services file were used for sampling and risk adjustment. We estimated risk-adjusted differences in patient-reported measures of care experience and changes in functional status, for beneficiaries treated by BPCI and comparison hospitals. We selected a stratified random sample of BPCI and matched comparison beneficiaries. We fielded nine waves of surveys using a mail and phone protocol, yielding 29193 BPCI and 29913 comparison respondents. Most BPCI and comparison survey respondents reported a positive care experience and high satisfaction. BPCI respondents were slightly less likely than comparison respondents to report positive care experience or high satisfaction. Despite these differences in care experience, there was no difference between BPCI and comparison respondents in self-reported functional status approximately 90days after hospital discharge. These findings reduce concerns that BPCI may have unintentionally harmed patient health but suggest room for improvement in patient care experience.

Medicare's Bundled Payments For Care Improvement Initiative Maintained Quality Of Care For Vulnerable Patients.

The Bundled Payments for Care Improvement (BPCI) initiative established four models to test whether linking payments for an episode of care could reduce Medicare payments while maintaining or improving quality. Evaluations concluded that model 2, the largest, generally lowered payments without reducing quality for the average beneficiary, but these global results could mask adverse findings among vulnerable subpopulations. We analyzed changes in emergency department visits, unplanned hospital readmissions, and all-cause mortality within ninety days of hospital discharge among beneficiaries with one or more of three vulnerable characteristics-dementia, dual eligibility for Medicare and Medicaid, and recent institutional care-in 105,458 beneficiary episodes in the period October2013-December2016. The results for twelve types of medical and surgical BPCI episodes were evaluated relative to results in matched comparison groups. Our findings suggest that BPCI model 2 did not adversely affect care quality for beneficiaries with vulnerabilities. While this conclusion does not discourage the further development of bundled payment models, policy makers should support ongoing research to ensure that vulnerable populations are not adversely affected by these approaches.

Post-Acute Care After Joint Replacement in Medicare's Bundled Payments for Care Improvement Initiative.

Bundled payments, in which services provided around a care episode are linked together, are being tested under Medicare's Bundled Payments for Care Improvement (BPCI) program. Reducing post-acute care (PAC) is critical under bundled payment, but little is known about whether this is done through provider selection or consolidation, and whether particular patterns of changes in PAC are associated with success under the program. To characterize patterns of change in PAC under lower-extremity joint replacement episodes in BPCI. Retrospective difference-in-differences study. US Medicare, 2013 to 2015. A total of 264 US hospitals participating in BPCI for lower-extremity joint replacement and matched controls. Participation in BPCI. Use and duration of institutional PAC (proportion discharged to a skilled nursing facility, an inpatient rehabilitation facility, and a long-term care hospital), dispersion of PAC (proportion of discharges to commonly used providers), and quality of PAC (Star Ratings, readmission rates, length of stay, and nurse staffing); part A Medicare payments. BPCI participants decreased the use and duration of institutional PAC compared to controls: overall institutional PAC declined 4.4% in BPCI hospitals vs 2.1% in non-BPCI hospitals (difference = -2.2%; P = .033), and duration decreased by 1.6 days in BPCI hospitals compared to 0.0 days in non-BPCI hospitals (difference in differences = -1.5 days; P < .001). However, BPCI participants did not change their PAC referral patterns to reduce dispersion or refer patients to higher-quality PAC providers. Hospitals that were more successful in reducing Medicare payments started with higher payments and higher use of institutional PAC settings and demonstrated greater drops in use and duration of institutional PAC, but no differences in dispersion or referral to high-quality providers. Reductions in spending under BPCI were driven by a shift from higher- to lower-cost discharge settings, and by shortening the duration of institutional PAC. Hospitals that reduced payments the most had the highest spending at baseline. J Am Geriatr Soc 67:1027-1035, 2019.

Lack of Cost Savings for Lumbar Spine Fusions After Bundled Payments for Care Improvement Initiative

Retrospective analysis of Medicare claims and procedure details from a single institution participation in the Bundled Payments for Care Improvement (BPCI) program. To analyze the effects of the BPCI program on patient outcome metrics and cost data. The BPCI program was designed to improve the value of care provided to patients, but the financial consequences of this system remain largely unknown. We present 2 years of data from participation in the lumbar spine fusion bundle at a large, urban, academic institution. In 2013 and 2014, all Medicare patients undergoing lumbar spine fusions for DGR 459 (spinal fusion except cervical with major complication or comorbidity [MCC]) and 460 (without MCC) at our institution were enrolled in the BPCI program. We compared the BPCI cohort to a baseline cohort of patients under the same diagnosis related groups (DRGs) from 2009 to 2012 from which the target price was established. Three hundred fifty patients were enrolled into the BPCI program, while the baseline group contained 518 patients. When compared with the baseline cohort, length of stay decreased (4.58 ± 2.51 vs. 5.13 ± 3.75; P = 0.009), readmission rate was unchanged, and discharges with home health aid increased. Nonetheless, we were unable to effect an episode-based cost savings ($52,655 ± 27,028 vs. $48,913 ± 24,764). In the larger DRG 460 group, total payments increased in the BPCI group ($51,105 ± 26,347 vs. $45,934 ± 19,638, P = 0.001). Operative data demonstrated a more complex patient mix in the BPCI cohort. The use of interbody fusions increased from 2% to 16% (P < 0.001), and the percentage of complex spines increased from 23% to 45% (P < 0.001). Increased case complexity was responsible for increasing costs relative to the negotiated baseline target price. This payment system may discourage advancement in spine surgery due to the financial penalty associated with novel techniques and technologies. 3.

Skilled Nursing Facility Participation in Medicare’s Bundled Payments for Care Improvement Initiative: A Retrospective Study

ObjectiveTo investigate differences in facility characteristics, patient characteristics, and outcomes between skilled nursing facilities (SNFs) that participated in Medicare’s voluntary Bundled Payments for Care Improvement (BPCI) initiative and nonparticipants, prior to BPCI. DesignRetrospective, cross-sectional comparison of BPCI participants and nonparticipants. SettingSNFs. ParticipantsAll Medicare-certified SNFs (N=15,172) and their 2011-2012 episodes of care for chronic obstructive pulmonary disease, congestive heart failure, femur and hip/pelvis fracture, hip and femur procedures, lower extremity joint replacement, and pneumonia (N=873,739). InterventionsParticipation in a bundled payment program that included taking financial responsibility for care within a 90-day episode. Main Outcome MeasuresThis study investigates the characteristics of bundled payment participants and their patient characteristics and outcomes relative to nonparticipants prior to BPCI, to understand the implications of a broader implementation of bundled payments. ResultsSNFs participating in BPCI were more likely to be in urban areas (80.8%-98.4% vs 69.5%) and belong to a chain or system (73.8%-85.5% vs 55%), and were less likely to be located in the south (13.1%-20.2% vs 35.4%). Quality performance was similar or higher in most cases for SNFs participating in BPCI relative to nonparticipants. In addition, BPCI participants admitted higher socioeconomic status patients with similar clinical characteristics. Initial SNF length of stay was shorter and hospital readmission rates were lower for BPCI patients compared to nonparticipant patients. ConclusionsWe found that SNFs participating in the second financial risk-bearing phase of BPCI represented a diversity of SNF types, regions, and levels of quality and the results may provide insight into a broader adoption of bundled payment for postacute providers.

Hospitals Using Bundled Payment Report Reducing Skilled Nursing Facility Use And Improving Care Integration.

A goal of Medicare's bundled payment models is to improve quality and control costs after hospital discharge. Little is known about how participating hospitals are focusing their efforts to achieve these objectives, particularly around the use of skilled nursing facilities (SNFs). To understand hospitals' approaches, we conducted semistructured interviews with an executive or administrator in each of twenty-two hospitals and health systems participating in Medicare's Comprehensive Care for Joint Replacement model or its Bundled Payments for Care Improvement initiative for lower extremity joint replacement episodes. We identified two major organizational responses. One principal strategy was to reduce SNF referrals, using risk-stratification tools, patient education, home care supports, and linkages with home health agencies to facilitate discharges to home. Another was to enhance integration with SNFs: fifteen hospitals or health systems in our sample had formed networks of preferred SNFs to exert influence over SNF quality and costs. Common coordination strategies included sharing access to electronic medical records, embedding providers across facilities, hiring dedicated care coordination staff, and creating platforms for data sharing. As hospitals presumably move toward home-based care and more selective SNF referrals, more evidence is needed to understand how these discharge practices affect the quality of care and patient outcomes.

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.