Association of Bundled Payments for Joint Replacement Surgery and Patient Outcomes With Simultaneous Hospital Participation in Accountable Care Organizations

Emanuel

et al. 2020

BMJ

Self Cite

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 an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or health service use.DesignQuasi-experimental difference-in-differences analysis.SettingUS hospitals participating in bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and propensity score matched to non-participating hospitals.Participants238 hospitals participating in the Bundled Payments for Care Improvement initiative (BPCI) and 1415 non-BPCI hospitals. 226 BPCI hospitals were matched to 700 non-BPCI hospitals.Main outcome measuresPrimary outcomes were total spending on episodes and death 90 days after discharge. Secondary outcomes included spending and use by type of post-acute care. BPCI and non-BPCI hospitals were compared by patient, hospital, and hospital market characteristics. Market characteristics included population size, competitiveness, and post-acute bed supply.ResultsIn the 226 BPCI hospitals, episodes of care totaled 261 163 in the baseline period and 93 562 in the treatment period compared with 211 208 and 78 643 in the 700 matched non-BPCI hospitals, respectively, with small differences in hospital and market characteristics after matching. Differing trends were seen for some patient characteristics (eg, mean age change −0.3 years at BPCI hospitals v non- BPCI hospitals, P<0.001). In the adjusted analysis, participation in BPCI was associated with a decrease in total episode spending (−1.2%, 95% confidence interval −2.3% to −0.2%). Spending on care at skilled nursing facilities decreased (−6.3%, −10.0% to −2.5%) owing to a reduced number of facility days (−6.2%, −9.8% to −2.6%), and home health spending increased (4.4%, 1.4% to 7.5%). Mortality at 90 days did not change (−0.1 percentage points, 95% confidence interval −0.5 to 0.2 percentage points).ConclusionsIn this longer term evaluation of a large national programme on medical bundled payments in the US, participation in bundles for four common medical conditions was associated with savings at three years. The savings were generated by practice changes that decreased use of high intensity care after hospital discharge without affecting quality, which also suggests that bundles for medical conditions could require multiple years before changes in savings and practice emerge.

Section: Discussionmentioning

confidence: 99%

“…Covariates were chosen based on previous studies 111316363738. Patient level covariates included age, sex, race, disability status, Medicare and Medicaid dual eligibility status, Elixhauser comorbidities, and admission diagnosis related group 39.…”

Section: Methodsmentioning

confidence: 99%

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

Rolnick

Emanuel

et al. 2020

BMJ

Self Cite

“…Covariates were chosen based on prior studies and included patient variables such as age, sex, Elixhauser comorbidities, frailty, and Medicare/ Medicaid dual-eligibility status. [17][18][19][20][21][22][23] Additionally, our analysis included market variables such as population size and Medicare Advantage penetration.…”

Section: Exposure and Covariate Variablesmentioning

confidence: 99%

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

Journal of Hospital Medicine

Chatterjee

Wang

et al. 2021

Self Cite

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.

“…Leaders can minimize diffusion of responsibility by giving individual clinicians clear direction about their roles and accountability. 9 As evidenced by contemporary valuebased programs 10 and payment codes that encourage delivery of transitional care, 11 individual incentives can be promising strategies for achieving this accountability. This is particularly true when incentives are designed and implemented using the behavioral economics principles of choice overload and goal gradients.…”

Section: Individual Incentive Designmentioning

confidence: 99%

How to Keep Diffusion of Responsibility From Undermining Value-Based Care

Marcotte

Krimmel-Morrison

2020

AMA Journal of Ethics

Diffusion of responsibility describes how individuals can underperform in circumstances of shared accountability. While not well studied in health care settings, this phenomenon is an unintended consequence of the health care sector's complexity and fragmentation. This article considers 3 ways in which monetary and nonmonetary incentives can mitigate negative consequences of diffusion of responsibility. First, incentives should be finite and focused. Second, health care organizations can incentivize both individual and team performance. Third, organizations can use peer comparison feedback to amplify effective incentivizing strategies. Diffusion of Responsibility Diffusion of responsibility describes how individuals can underperform in circumstances of shared accountability. While not well studied in health care settings, the phenomenon has been described in a number of other fields. 1,2,3 It increasingly represents a concern in health care, as care delivery complexity increases and the nation continues to shift toward value-based programs that hold clinicians and organizations financially accountable for the quality and costs of care. Consider care fragmentation-which occurs when patients receive care from multiple clinicians without a main one who guides or coordinates care 4-as a prominent manifestation of diffusion of responsibility. When patients receive care from multiple clinicians in multiple organizations, diffusion of reponsibility can result if each clinician assumes that others have taken on the role of coordination for a patient's care. 5 Unfortunately, a growing body of data demonstrates that higher levels of care fragmentation are associated with adverse outcomes, including increased emergency room, hospitalization, and total health care spending. 6,7