Dataset Information

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

ABSTRACT:

Background

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.

Objective

To evaluate whether hospital safety net status affected the association between bundled payment participation and medical episode outcomes.

Design, setting, and participants

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.

Exposure(s)

Hospital BPCI participation and safety net status.

Main outcome(s) and measure(s)

The primary outcome was postdischarge spending. Secondary outcomes included quality and post-acute care utilization measures.

Results

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.

Conclusions

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.

SUBMITTER: Liao JM

PROVIDER: S-EPMC8626055 | biostudies-literature | 2021 Dec

REPOSITORIES: biostudies-literature

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Publications

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

Liao Joshua M JM Chatterjee Paula P Wang Erkuan E Connolly John J Zhu Jingsan J Cousins Deborah S DS Navathe Amol S AS

Journal of hospital medicine 20211201 12

<h4>Background</h4>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.<h4>Objective</h4>To evaluate whether hospital safety net status affected the association between bundled payment participation and medical episode outcomes.<h4>Design, setting, and participants</h4>This observationa ...[more]

PMID: 34798000

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Project description:ImportanceReduced institutional postacute care has been associated with savings in alternative payment models. However, organizations may avoid voluntary participation if participation could threaten their own revenues.ObjectiveTo characterize the association between hospital-skilled nursing facility (SNF) integration and participation in Medicare's Bundled Payments for Care Improvement Advanced (BPCI-A) program.Design, setting, and participantsThis is a cross-sectional analysis of hospital participation in BPCI-A beginning with its launch in 2018. Each SNF-integrated hospital was matched with 2 nonintegrated hospitals for each of 4 episode-specific analyses. Fifteen hospital-level variables were used for matching: beds, case mix index, days, area SNF beds, metropolitan location, ownership, region, system membership, and teaching status. Hospitals were also matched on episode-specific volume, target price, and the interaction of target price and case mix. Episode-specific logistic models were estimated regressing hospital participation on integration and the previously listed variables. The marginal effect of integration on participation was then calculated. Analysis took place from August 2022 to May 2024.ExposureHospital-SNF integration, as defined by common ownership and referral patterns and identified using cost reports, Medicare claims, and Provider Enrollment, Chain, and Ownership System records. Additional sources included records of target prices and participation, the Area Health Resources File, and the Compendium of US Health Systems.Main outcomes and measuresParticipation in BPCI-A.ResultsIn total, 1524 hospitals met criteria for inclusion in the hip and femur (HFP) analysis, 1825 were included in the major joint replacement of the lower extremity (MJRLE) analysis, 2018 were included in the sepsis analysis, and 1564, were included in the stroke-specific analysis. Across episodes, 191 HFP-eligible hospitals (12.5% of HFP-eligible hospitals), 302 MJRLE-eligible hospitals (16.5%), 327 sepsis-eligible hospitals (16.2%), and 185 sepsis-eligible hospitals (11.8%) were SNF integrated. In total, 79 hospitals (5.2%) participated in the HFP episode, 128 (7.0%) participated in the MJRLE episode, 204 (10.1%) participated in the sepsis episode, and 141 (9.0%) participated in the stroke episode. Integration was associated with a 4.7-percentage point decrease (95% CI, 2.4 to 6.9 percentage points) in participation in the MJRLE episode. There was no association between integration and participation for HFP (0.5-percentage point increase in participation moving from nonintegrated to integrated; 95% CI, -2.9 to 3.8 percentage points), sepsis (1.0-percentage point increase; 95% CI, -2.2 to 4.2 percentage points), and stroke (0.3-percentage point decrease; 95% CI, -3.1 to 3.8 percentage points).Conclusions and relevanceIn this cross-sectional study, there was an uneven association between hospital-SNF integration and participation in Medicare's BPCI-A program. Other factors may be more consistent determinants of selection into voluntary payment reform.

Project description:IntroductionOrthopaedic care is shifting to alternative payment models. We examined whether New York University Langone Medical Center achieved savings under the Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement initiative.MethodsThis study was a difference-in-differences study of Medicare fee-for-service patients hospitalized from April 2011 to June 2012 and October 2013 to December 2014 for lower extremity joint arthroplasty, cardiac valve procedures, or spine surgery (intervention groups), or for congestive heart failure, major bowel procedures, medical peripheral vascular disorders, medical noninfectious orthopaedic care, or stroke (control group). We examined total episode costs and costs by service category.ResultsWe included 2,940 intervention episodes and 1,474 control episodes. Relative to the trend in the control group, lower extremity joint arthroplasty episodes achieved the greatest savings: adjusted average episode cost during the intervention period decreased by $3,017 (95% confidence interval [CI], -$6,066 to $31). For cardiac procedures, the adjusted average episode cost decreased by $2,999 (95% CI, -$8,103 to $2,105), and for spinal fusion, it increased by $8,291 (95% CI, $2,879 to $13,703). Savings were driven predominantly by shifting postdischarge care from inpatient rehabilitation facilities to home. Spinal fusion index admission costs increased because of changes in surgical technique.DiscussionUnder bundled payment, New York University Langone Medical Center decreased total episode costs in patients undergoing lower extremity joint arthroplasty. For patients undergoing cardiac valve procedures, evidence of savings was not as strong, and for patients undergoing spinal fusion, total episode costs increased. For all three conditions, the proportion of patients referred to inpatient rehabilitation facilities upon discharge decreased. These changes were not associated with an increase in index hospital length of stay or readmission rate.ConclusionOpportunities for savings under bundled payment may be greater for lower extremity joint arthroplasty than for other conditions.

Project description:BackgroundDistal radius fractures are the most common fracture of childhood, occurring in ∼1 per 100 children annually. Given the high incidence of these fractures, we explored feasibility of a bundled payment model. We determined the total treatment costs for each child and identified components of fracture management that contributed to variations in cost.MethodsWe retrospectively reviewed all hospital and physician costs related to the treatment of closed distal radius fractures at a large academic children's hospital. We included all children age 2 to 15 years treated by an orthopaedic surgeon for an isolated closed distal radius fracture between 2013 and 2015. We compared total treatment costs by fracture management approach. We then estimated the contribution of each component of fracture management to total treatment costs using linear regression.ResultsWe identified 5640 children meeting the inclusion criteria, of which 4602 (81.6%) received closed treatment without manipulation, 922 (16.3%) underwent closed reduction in the clinic, emergency department, or radiology procedure suite, and 116 (2.1%) underwent treatment in the operating room. The median cost for closed treatment without manipulation was $1390 [interquartile range (IQR) 1029 to 1801], compared with $4263 (IQR, 3740 to 4832) for closed reduction and $9389 (IQR, 8272 to 11,119) for closed reduction and percutaneous pinning (P<0.001). In multivariable regression analysis, fracture management approach and use of the operating room environment were the largest cost drivers (P<0.001, R=0.88). Closed reduction in the clinic or emergency department added $894 (95% confidence interval, 819-969) to treatment costs, while closed reduction in the operating room added $5568 (95% confidence interval, 5224-6297). Location of the initial clinical evaluation, number of radiographic imaging series obtained, and number of orthopaedic clinic visits also contributed to total costs.ConclusionsClosed pediatric distal radius fractures treated without manipulation show small variations in treatment costs, making them well suited for bundled payment. Bundled payments for these fractures could reduce costs by encouraging adoption of existing evidence-based practices.Level of evidenceLevel III-therapeutic.

Project description:ObjectiveThe 340B program allows safety-net hospitals to acquire discounted outpatient drugs and charge payers full price. We examined whether 340B participation increases safety-net engagement.Data sources340B participation data, Medicare hospital cost reports, American Hospital Association Survey, and Schedule 990 nonprofit hospital tax returns.Study designQuasi-experimental difference-in-differences design comparing 340B hospitals (the "treatment" group) before and after participating to changes over time to three alternative "control" groups: all other nonprofit and public hospitals, hospitals that are not participating during our study, and hospitals that were not-yet-participating but started after 2015. Outcome measures include a range of safety-net care measures that are alternatives to the standard uncompensated care: charity care, community benefit spending, charity care policies, and low-profit service-line provision.Data extractionWe extracted data on all nonprofit and public hospitals from 2011 to 2015. We linked 340B participation data to Medicare hospital cost reports and American Hospital Association data using Medicare hospital identifiers. 990 Data was linked on name and address.Principal findingsNew 340B participation was not associated with a change in uncompensated care, but was associated with a 28.9 percent increase in charity care spending (SE = 8.8), or about $880,000 per hospital. However, total community benefit spending (including charity care) did not change. 340B was associated with an increase in the probability of offering discounted care (4.3 percentage points, SE = 1.6) from 84 to 88 percent and an increase in the income eligibility limit for discounted care (18.9 percentage points, SE = 5.6) from 294 to 313 percent. Participation was not associated with the probability of offering low-profit medical care services.ConclusionsAlternative measures show that newly participating hospitals may increase charity care, potentially through offering more patients discounted care. However, increases appear to be fully offset by reductions in other community benefit programs.

Project description:Policy Points Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee-for-service contracting, although bundled payment models may not reduce absolute costs. Bundled payments may be more effective than fee-for-service payments in containing costs for certain medical conditions. For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions. Bundled payment contracting involves trade-offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee-for-service payment.ContextBundled payments have been promoted as an alternative to fee-for-service payments that can mitigate the incentives for service volume under the fee-for-service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality.MethodsWe examined the history and features of 16 of Medicare's bundled payment programs involving hospital-initiated episodes of care and conducted a literature review of articles about those programs. Database and additional searches yielded 1,479 articles. We evaluate the studies' methodological quality and summarize the quantitative findings about Medicare expenditures and quality of care from 37 studies that used higher-quality research designs.FindingsMedicare's bundled payment initiatives have varied in their design features, such as episode scope and duration. Many initiatives were associated with little to no reduction in Medicare expenditures, unless large pricing discounts for providers were negotiated in advance. Initiatives that included post-acute care services were associated with lower expenditures for certain conditions. Hospitals may have been able to reduce internal production costs with help from physicians via gainsharing. Most initiatives were not associated with significant changes in quality of care, as measured by readmission and mortality rates. Of the significant changes in readmission rates, the results were mixed, showing increases and decreases associated with bundled payments. Some evidence suggested that worse patient outcomes were associated bundled payments, although most results were not statistically significant. Results on case-mix selection were mixed: Several initiatives were associated with reductions in episode severity, whereas others were associated with little change.ConclusionsBundled payments for hospital-initiated episodes may be a good alternative to fee-for-service payments. Bundled payments can help slow the growth of payer spending, although they do not necessarily reduce absolute spending. They are associated with lower provider production costs, and there is no overwhelming evidence of compromised quality. However, designing a bundled payment contract that is attractive to both providers and payers proves to be a challenge.

Project description:ImportanceMedicare'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.ObjectiveTo evaluate whether hospital BPCI participation for LEJR was associated with changes in overall volume and case mix.Design, setting, and participantsObservational 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.ExposuresHospital BPCI participation.Main outcomes and measuresChanges 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.ResultsAmong 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.Conclusions and relevanceIn 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.

Dataset Information

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

Background

Objective

Design, setting, and participants

Exposure(s)

Main outcome(s) and measure(s)

Results

Conclusions

Publications

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

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