Medical and Surgical Episodes Among Hospital Participants in the Bundled Payments for Care Improvement-Advanced Program

Abstract

Importance: Hospital participation in the Bundled Payments for Care Improvement-Advanced (BPCI-A) initiative has been associated with modest savings and stable clinical outcomes overall, but it is unknown whether the program performs differently for medical and surgical or procedural (henceforth, surgical) episodes.

Objective: To assess the association of BPCI-A participation with Medicare spending and clinical outcomes for medical and surgical episodes.

Design, setting, and participants: This retrospective difference-in-differences cohort study utilized 100% Medicare fee-for-service inpatient claims for episodes initiated between January 1, 2017, and September 30, 2019, and included 90 days of follow-up. The setting was hospitals participating in BPCI-A and matched nonparticipant hospitals. Participants included Medicare beneficiaries admitted for medical or surgical episodes.

Exposure: BPCI-A participation, beginning in 2018.

Main outcomes and measures: Changes in 90-day Medicare payments and clinical outcomes (readmissions, mortality, healthy days at home).

Results: The final sample included 2 895 878 episodes; 1 618 172 (55.9%) were female, 324 186 (11.2%) people under age 65 years, 1 354 246 (46.8%) between 65 and 80 years of age, and 1 217 446 (42.0%) over 80 years of age. Patient characteristics at BPCI-A and comparison hospitals were similar. BPCI-A participation was associated with a decrease in payments for medical episodes (-$882 per episode; 95% CI -$1004 to -$760) and surgical episodes (-$587; 95% CI -$850 to -$324) compared with nonparticipant hospitals (absolute difference between change in medical and surgical episodes, -$295; 95% CI -$584 to -$5). BPCI-A participation was associated with a greater increase in healthy days at home and a greater decrease in both skilled nursing facility (SNF) admissions and SNF length of stay overall, but there were no significant differences between medical and surgical episodes in terms of the association of BPCI-A with changes in these outcomes.

Conclusions and relevance: In this cohort study analyzing the outcomes of the BPCI-A program for medical and surgical episodes, BPCI-A participation was associated with modestly decreased payments for both medical and surgical episodes compared with nonparticipants. Improvements in clinical outcomes associated with BPCI-A participation were also modest for both types of episodes; this study does not support a hypothesis that either medical or surgical episodes are better-suited for episode-based payments.

Figure 1.. Medicare Payments per Episode for Bundled Payments for Care Improvement–Advanced (BPCI-A) vs Comparison Hospitals

BPCI-A Med indicates, medical episode at BPCI-A participating hospital; BPCI-A Surg, surgical episode at BPCI-A participating hospital; Comp Med, medical episode at comparison hospital; Comp Surg, surgical episode at comparison hospital; Q, quarter.

Figure 2.. Differences in Medicare Payment Changes for Hospitals With Bundled Payments for Care Improvement–Advanced Participation vs Nonparticipants

AMI indicates acute myocardial infarction (n = 219 matched Bundled Payments for Care Improvement–Advanced participating hospitals); arrhythmia, cardiac arrhythmia (n = 277); back and neck, back and neck except spinal fusion (n = 47); CABG, coronary artery bypass graft (n = 62); CHF, congestive heart failure (n = 355); COPD, chronic obstructive pulmonary disease, bronchitis, asthma (n = 229); defibrillator, cardiac defibrillator (n = 6); DJR-LE, double joint replacement of the lower extremity (n = 2); fractures, fractures of the femur and hip or pelvis (n = 43); GI, gastrointestinal; hip/femur (non-MJR), hip and femur procedures except major joint (n = 138); liver disorders, disorders of the liver except malignant neoplasm, cirrhosis, alcoholic hepatitis (n = 34); lower extremity/humerus, lower extremity and/or humerus procedure except hip, foot, femur (n = 67); MBP, major bowel procedure (n = 37); MJR-LE, major joint replacement of the lower extremity (n = 144); MJR-UE, major joint replacement of the upper extremity (n = 37); PCI, percutaneous coronary intervention (n = 72); pneumonia, simple pneumonia and respiratory infections (n = 263); spinal fusion (cervical), cervical spinal fusion (n = 47); spinal fusion (combined A/P), combined anterior posterior spinal fusion (n = 4); UTI, urinary tract infection (n = 227). ^aConditions included in Transforming Episode Accountability Model (TEAM) as well.