Year 1 of the Bundled Payments for Care Improvement-Advanced Model

Home Heart Hospital Associated With Reduced Hospitalizations and Costs Among High-Cost Patients With Cardiovascular Disease

BACKGROUND

There is no widely accepted care model for managing high-need, high-cost (HNHC) patients. We hypothesized that a Home Heart Hospital (H3), which provides longitudinal, hospital-level at-home care, would improve care quality and reduce costs for HNHC patients with cardiovascular disease (CVD).

OBJECTIVE

To evaluate associations between enrollment in H3, which provides longitudinal, hospital-level at-home care, care quality, and costs for HNHC patients with CVD.

METHODS

This retrospective within-subject cohort study used insurance claims and electronic health records data to evaluate unadjusted and adjusted annualized hospitalization rates, total costs of care, part A costs, and mortality rates before, during, and following H3.

RESULTS

Ninety-four patients were enrolled in H3 between February 2019 and October 2021. Patients' mean age was 75 years and 50% were female. Common comorbidities included congestive heart failure (50%), atrial fibrillation (37%), coronary artery disease (44%). Relative to pre-enrollment, enrollment in H3 was associated with significant reductions in annualized hospitalization rates (absolute reduction (AR): 2.4 hospitalizations/year, 95% confidence interval [95% CI]: -0.8, -4.0; p < 0.001; total costs of care (AR: -$56 990, 95% CI: -$105 170, -$8810; p < 0.05; and part A costs (AR: -$78 210, 95% CI: -$114 770, -$41 640; p < 0.001). Annualized post-H3 total costs and part A costs were significantly lower than pre-enrollment costs (total costs of care: -$113 510, 95% CI: -$151 340, -$65 320; p < 0.001; part A costs: -$84 480, 95% CI: -$121 040, -$47 920; p < 0.001).

CONCLUSIONS

Longitudinal home-based care models hold promise for improving quality and reducing healthcare spending for HNHC patients with CVD.

Physician Group Practices Accrued Large Bonuses Under Medicare's Bundled Payment Model, 2018-20

The Bundled Payments for Care Improvement Advanced Model (BPCI-A), a voluntary Alternative Payment Model for Medicare, incentivizes hospitals and physician group practices to reduce spending for patient care episodes below preset target prices. The experience of physician groups in BPCI-A is not well understood. We found that physician groups earned $421 million in incentive payments during BPCI-A's first four performance periods (2018-20). Target prices were positively associated with bonuses, with a mean reconciliation payment of $139 per episode in the lowest decile of target prices and $2,775 in the highest decile. In the first year of the COVID-19 pandemic, mean bonuses increased from $815 per episode to $2,736 per episode. These findings suggest that further policy changes, such as improving target price accuracy and refining participation rules, will be important as the Centers for Medicare and Medicaid Services continues to expand BPCI-A and develop other bundled payment models.

Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations

BACKGROUND

Medicare's voluntary bundled payment programs have demonstrated generally favorable results. However, it remains unknown whether uneven hospital participation in these programs in communities with greater shares of minorities and patients of low socioeconomic status results in disparate access to practice redesign innovations.

OBJECTIVE

Examine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced).

DESIGN

Cross-sectional study using ordinary least squares regression controlling for patient and community factors.

PARTICIPANTS

Medicare fee-for-service patients enrolled from 2015-2017 (pre-BPCI-Advanced) and residing in 2,058 local communities nationwide defined by Hospital Service Areas (HSAs). Each community's share of marginalized patients was calculated separately for each of the share of beneficiaries of Black race, Hispanic ethnicity, or dual eligibility for Medicare and Medicaid.

MAIN MEASURES

Dichotomous variable indicating whether a given community had at least one hospital that ever participated in BPCI-Advanced from 2018-2022.

KEY RESULTS

Communities with higher shares of dual-eligible individuals were less likely to be served by a hospital participating in BPCI-Advanced than communities with the lowest quartile of dual-eligible individuals (Q4: -15.1 percentage points [pp] lower than Q1, 95% CI: -21.0 to -9.1, p < 0.001). There was no consistent significant relationship between community proportion of Black beneficiaries and likelihood of having a hospital participating in BPCI-Advanced. Communities with higher shares of Hispanic beneficiaries were more likely to have a hospital participating in BPCI-Advanced than those in the lowest quartile (Q4: 19.2 pp higher than Q1, 95% CI: 13.4 to 24.9, p < 0.001).

CONCLUSIONS

Communities with greater shares of dual-eligible beneficiaries, but not racial or ethnic minorities, were less likely to be served by a hospital participating in BPCI-Advanced Policymakers should consider approaches to incentivize more socioeconomically uniform participation in voluntary bundled payments.

Bundled Payments for Care Improvement and Quality of Care and Outcomes in Heart Failure

Importance

The Centers for Medicare & Medicaid Services (CMS) Bundled Payments for Care Improvement (BPCI) program was launched in 2013 with a goal to improve care quality while lowering costs to Medicare.

Objective

To compare changes in the quality and outcomes of care for patients hospitalized with heart failure according to hospital participation in the BPCI program.

Design, Setting, and Participants

This cross-sectional study used a difference-in-difference approach to evaluate the BPCI program in 18 BPCI hospitals vs 211 same-state non-BPCI hospitals for various process-of-care measures and outcomes using American Heart Association Get With The Guidelines-Heart Failure registry and CMS Medicare claims data from November 1, 2008, to August 31, 2018. Data were analyzed from May 2022 to May 2023.

Exposures

Hospital participation in CMS BPCI Model 2 Heart Failure, which paid hospitals in a fee-for-service process and then shared savings or required reimbursement depending on how the total cost of an episode of care compared with a target price.

Main Outcomes and Measures

Primary end points included 7 quality-of-care measures. Secondary end points included 9 outcome measures, including in-hospital mortality and hospital-level risk-adjusted 30-day and 90-day all-cause readmission rate and mortality rate.

Results

During the study period, 8721 patients were hospitalized in the 23 BPCI hospitals and 94 530 patients were hospitalized in the 224 same-state non-BPCI hospitals. Less than a third of patients (30 723 patients, 29.8%) were 75 years or younger; 54 629 (52.9%) were female, and 48 622 (47.1%) were male. Hospital participation in BPCI Model 2 was not associated with significant differential changes in the odds of various process-of-care measures, except for a decreased odds of evidence-based β-blocker at discharge (adjusted odds ratio [aOR], 0.63; 95% CI, 0.41-0.98; P = .04). Participation in the BPCI was not associated with a significant differential change in the odds of receiving angiotensin-converting enzyme inhibitors/angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors at discharge, receiving an aldosterone antagonist at discharge, having a cardiac resynchronization therapy (CRT)-defibrillator or CRT pacemaker placed or prescribed at discharge, having implantable cardioverter-defibrillator (ICD) counseling or an ICD placed or prescribed at discharge, heart failure education being provided among eligible patients, or having a follow-up visit within 7 days or less. Participation in the BPCI was associated with a significant decrease in odds of in-hospital mortality (aOR, 0.67; 95% CI, 0.51-0.86; P = .002). Participation was not associated with a significant differential change in hospital-level risk-adjusted 30-day or 90-day all-cause readmission rate and 30-day or 90-day all-cause mortality rate.

Conclusion and Relevance

In this study, hospital participation in the BPCI Model 2 Heart Failure program was not associated with improvement in process-of-care quality measures or 30-day or 90-day risk-adjusted all-cause mortality and readmission rates.

Association of bundled payments with spending, utilization, and quality for surgical conditions: A scoping review

OBJECTIVES

To assess the body of literature examining episode-based bundled payment models effect on health care spending, utilization, and quality of care for surgical conditions.

BACKGROUND SUMMARY

Episode-based bundled payments were developed as a strategy to lower healthcare spending and improve coordination across phases of healthcare. Surgical conditions may be well-suited targets for bundled payments because they often have defined periods of care and widely variable healthcare spending. In bundled payment models, hospitals receive financial incentives to reduce spending on care provided to patients during a predefined clinical episode. Despite the recent proliferation of bundles for surgical conditions, a collective understanding of their effect is not yet clear.

METHODS

A scoping review was conducted, and four databases were queried from inception through September 27, 2021, with search strings for bundled payments and surgery. All studies were screened independently by two authors for inclusion.

RESULTS

Our search strategy yielded a total of 879 unique articles of which 222 underwent a full-text review and 28 met final inclusion criteria. Of these studies, most (23 of 28) evaluated the impact of voluntary bundled payments in orthopedic surgery and found that bundled payments are associated with reduced spending on total care episodes, attributed primarily to decreases in post-acute care spending. Despite reduced spending, clinical outcomes (e.g., readmissions, complications, and mortality) were not worsened by participation. Evidence supporting the effects of bundled payments on cost and clinical outcomes in other non-orthopedic surgical conditions remains limited.

CONCLUSIONS

Present evaluations of bundled payments primarily focus on orthopedic conditions and demonstrate cost savings without compromising clinical outcomes. Evidence for the effect of bundles on other surgical conditions and implications for quality and access to care remain limited.

Hospital-level variation in hospitalization costs for spinal fusion in the United States

BACKGROUND

With a growing emphasis on value of care, understanding factors associated with rising healthcare costs is increasingly important. In this national study, we evaluated the degree of center-level variation in the cost of spinal fusion.

METHODS

All adults undergoing elective spinal fusion were identified in the 2016 to 2020 National Inpatient Sample. Multilevel mixed-effect models were used to rank hospitals based on risk-adjusted costs. The interclass coefficient (ICC) was utilized to tabulate the amount of variation attributable to hospital-level characteristics. The association of high cost-hospital (HCH) status with in-hospital mortality, perioperative complications, and overall resource utilization was analyzed. Predictors of increased costs were secondarily explored.

RESULTS

An estimated 1,541,740 patients underwent spinal fusion, and HCH performed an average of 9.5% of annual cases. HCH were more likely to be small (36.8 vs 30.5%, p<0.001), rural (10.1 vs 8.8%, p<0.001), and located in the Western geographic region (49.9 vs 16.7%, p<0.001). The ICC demonstrated 32% of variation in cost was attributable to the hospital, independent of patient-level characteristics. Patients who received a spinal fusion at a HCH faced similar odds of mortality (0.74 [0.48-1.15], p = 0.18) and perioperative complications (1.04 [0.93-1.16], p = 0.52), but increased odds of non-home discharge (1.30 [1.17-1.45], p<0.001) and prolonged length of stay (β 0.34 [0.26-0.42] days, p = 0.18). Patient factors such as gender, race, and income quartile significantly impacted costs.

CONCLUSION

The present analysis identified 32% of the observed variation to be attributable to hospital-level characteristics. HCH status was not associated with increased mortality or perioperative complications.

THE ROLE OF HEALTH POLICY IN IMPROVING HEALTH OUTCOMES AND HEALTH EQUITY

Despite higher per-capita health care spending than any other country, the United States lags far behind in health outcomes. Additionally, there are significant health inequities by race, ethnicity, socioeconomic position, and rurality. One set of potential solutions to improve these outcomes and reduce inequities is through health policy. Policy focused on improving access to care through insurance coverage, such as the Affordable Care Act's Medicaid expansion, has led to better health and reduced mortality. Policy aimed at improving health care delivery, including value-based payment and alternative payment models, has improved quality of care but has had little impact on population health outcomes. Policies that influence broader issues of economic opportunity likely have a strong influence on health, but lack the evidence base of more targeted interventions. To advance health outcomes and equity, further policy change is crucial.

Health-Care Patterns for Three Common Elective Surgeries: Implications for Bundled Payment Models

INTRODUCTION

The study objectives were to assess the timing, duration, and nature of health-care service utilization before and after three common elective surgical procedures not currently included in federal episode-based bundled payment programs.

METHODS

We performed a retrospective cohort study of patients undergoing one of three low-risk surgical procedures (breast reduction, upper extremity nerve decompression, and panniculectomy) between 2010 and 2017 using a private insurer's national claims database. All professional and facility billing claims for health-care services were identified during the 12-mo preoperative and 12-mo postoperative periods for each patient. We compared trends in monthly utilization of health-care services to estimate surgery-related utilization patterns with interrupted time series analyses.

RESULTS

The cohort included 7885 patients receiving breast reduction, 99,404 patients receiving upper extremity nerve decompression, and 955 patients receiving panniculectomy. The mean monthly encounters gradually increased before each procedure, with a gradual decline in services postoperatively. Claims in the preoperative period for all procedures were primarily diagnostic testing and outpatient evaluation and management. There was limited use of postacute care services across the surgical procedures. There were notable differences in service utilization between the three surgeries, including differing inflection points for preoperative services (approximately 7 mo for breast reduction and panniculectomy, compared with at least 9 mo for nerve decompression) and postoperative services (up to 3 mo for panniculectomy and 4 mo for nerve decompression, compared with 6 mo for breast reduction).

CONCLUSIONS

This study highlights important differences in utilization of health-care services by type of surgery. These findings suggest that prior to expanding episode-based bundled payment models to surgical conditions with limited utilization of postacute care services and fewer complications, the Centers for Medicare and Medicaid Services and private payers should consider tailoring the timing and duration of clinical episodes to individual surgical procedures.

Changes in Cardiovascular Spending, Care Utilization, and Clinical Outcomes Associated With Participation in Bundled Payments for Care Improvement - Advanced

BACKGROUND

Bundled Payments for Care Improvement - Advanced (BPCI-A) is a Medicare initiative that aims to incentivize reductions in spending for episodes of care that start with a hospitalization and end 90 days after discharge. Cardiovascular disease, an important driver of Medicare spending, is one of the areas of focus BPCI-A. It is unknown whether BPCI-A is associated with spending reductions or quality improvements for the 3 cardiovascular medical events or 5 cardiovascular procedures in the model.

METHODS

In this retrospective cohort study, we conducted difference-in-differences analyses using Medicare claims for patients discharged between January 1, 2017, and September 30, 2019, to assess differences between BPCI-A hospitals and matched nonparticipating control hospitals. Our primary outcomes were the differential changes in spending, before versus after implementation of BPCI-A, for cardiac medical and procedural conditions at BPCI-A hospitals compared with controls. Secondary outcomes included changes in patient complexity, care utilization, healthy days at home, readmissions, and mortality.

RESULTS

Baseline spending for cardiac medical episodes at BPCI-A hospitals was $25 606. The differential change in spending for cardiac medical episodes at BPCI-A versus control hospitals was $16 (95% CI, -$228 to $261; P=0.90). Baseline spending for cardiac procedural episodes at BPCI-A hospitals was $37 961. The differential change in spending for cardiac procedural episodes was $171 (95% CI, -$429 to $772; P=0.58). There were minimal differential changes in physicians' care patterns such as the complexity of treated patients or in their care utilization. At BPCI-A versus control hospitals, there were no significant differential changes in rates of 90-day readmissions (differential change, 0.27% [95% CI, -0.25% to 0.80%] for medical episodes; differential change, 0.31% [95% CI, -0.98% to 1.60%] for procedural episodes) or mortality (differential change, -0.14% [95% CI, -0.50% to 0.23%] for medical episodes; differential change, -0.36% [95% CI, -1.25% to 0.54%] for procedural episodes).

CONCLUSIONS

Participation in BPCI-A was not associated with spending reductions, changes in care utilization, or quality improvements for the cardiovascular medical events or procedures offered in the model.

Trends in healthy days at home for Medicare beneficiaries using the emergency department

BACKGROUND

Older adults, particularly those with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), have high rates of emergency department (ED) visits and are at risk for poor outcomes. How best to measure quality of care for this population has been debated. Healthy Days at Home (HDAH) is a broad outcome measure reflecting mortality and time spent in facility-based healthcare settings versus home. We examined trends in 30-day HDAH for Medicare beneficiaries after visiting the ED and compared trends by AD/ADRD status.

METHODS

We identified all ED visits among a national 20% sample of Medicare beneficiaries ages 68 and older from 2012 to 2018. For each visit, we calculated 30-day HDAH by subtracting mortality days and days spent in facility-based healthcare settings within 30 days of an ED visit. We calculated adjusted rates of HDAH using linear regression, accounting for hospital random effects, visit diagnosis, and patient characteristics. We compared rates of HDAH among beneficiaries with and without AD/ADRD, including accounting for nursing home (NH) residency status.

RESULTS

We found fewer adjusted 30-day HDAH after ED visits among patients with AD/ADRD compared to those without AD/ADRD (21.6 vs. 23.0). This difference was driven by a greater number of mortality days, SNF days, and, to a lesser degree, hospital observation days, ED visits, and long-term hospital days. From 2012 to 2018, individuals living with AD/ADRD had fewer HDAH each year but a greater mean annual increase over time (p < 0.001 for the interaction between year and AD/ADRD status). Being a NH resident was associated with fewer adjusted 30-day HDAH for beneficiaries with and without AD/ADRD.

CONCLUSIONS

Beneficiaries with AD/ADRD had fewer HDAH following an ED visit but saw moderately greater increases in HDAH over time compared to those without AD/ADRD. This trend was visit driven by declining mortality and utilization of inpatient and post-acute care.

Value-Based Payment for Clinicians Treating Cardiovascular Disease: A Policy Statement From the American Heart Association

Clinician payment is transitioning from fee-for-service to value-based payment, with reimbursement tied to health care quality and cost. However, the overarching goals of value-based payment-to improve health care quality, lower costs, or both-have been largely unmet. This policy statement reviews the current state of value-based payment and provides recommended best practices for future design and implementation. The policy statement is divided into sections that detail different aspects of value-based payment: (1) key program design features (patient population, quality measurement, cost measurement, and risk adjustment), (2) the role of equity during design and evaluation, (3) adjustment of payment, and (4) program implementation and evaluation. Each section introduces the topic, describes important considerations, and lists examples from existing programs. Each section includes recommended best practices for future program design. The policy statement highlights 4 key themes for successful value-based payment. First, programs should carefully weigh the incentives between lowering cost and improving quality of care and ensure that there is adequate focus on quality of care. Second, the expansion of value-based payment should be a tool for improving equity, which is central to quality of care and should be a focal point of program design and evaluation. Third, value-based payment should continue to move away from fee for service toward more flexible funding that allows clinicians to focus resources on the interventions that best help patients. Last, successful programs should find ways to channel clinicians' intrinsic motivation to improve their performance and the care for their patients. These principles should guide the future development of clinician value-based payment models.

The Medicare IPPS 40 Years Later: Lessons Learned and What to Do Next

The 1983 implementation of the Medicare Inpatient Prospective Payment System (IPPS) was successful in controlling Medicare inpatient costs because it was designed as a clinically credible management tool that facilitated real behavior change and performance improvement. The next phase of IPPS should expand the inpatient payment bundle to a hospital episode-of-care performance bundle that explicitly links episode cost and quality. A uniform, comparable, and transparent episode performance bundle that highlights the tradeoffs between episode cost and quality can expand the incentives to control costs and provide hospitals the management information to improve performance.

Cost Variation and Value of Care in Pulmonary Lobectomy Across the United States

BACKGROUND

Optimization of value, or quality relative to costs, has garnered significant attention in the United States. We aimed to characterize center-level variation in costs and quality after pulmonary lobectomy using a national cohort.

METHODS

Adults undergoing elective pulmonary lobectomy were identified in the 2016 to 2018 Nationwide Readmissions Database. Quality was defined by the absence of major adverse outcomes including respiratory failure, acute kidney injury, reoperation, and death. Risk-adjusted adverse outcome rates and costs were studied for institutions performing greater than or equal to 10 operations annually. Using observed-to-expected (O/E) ratios, high-value hospitals were defined as those with an O/E ratio less than 1 for costs and O/E ratio less than 1 for quality, while low-value hospitals were defined by the converse.

RESULTS

Among 95 446 patients managed at 565 hospitals annually, the median center-level cost for lobectomy was $22 000 (interquartile range, $18 000-$27 000), while the median adverse outcome rate was 14.3% (interquartile range, 8.3%-23.1%). Centers with an O/E ratio less than 1 for adverse events exhibited a $2200/case reduction in risk-adjusted costs. Using O/E ratios, 35.2% of centers were classified as high value while 18.6% were low value. Compared with low-value centers, high-value centers treated older patients (67.1 years of age vs 65.5 years of age; P < .001) with greater comorbidities (Elixhauser Comorbidity Index 3.7 vs 2.9; P < .001) but had greater annual lobectomy volume (40 cases vs 30 cases; P = .001) and were more commonly teaching hospitals.

CONCLUSIONS

Significant variation in costs and quality persists for lobectomy at the national level. Although high-value programs operated on patients at greater surgical risk, they had reduced complications and costs. Our findings suggest the need for dissemination of quality improvement and cost reduction practices.

Changes in Racial Equity Associated With Participation in the Bundled Payments for Care Improvement Advanced Program

IMPORTANCE

The Medicare alternative payment models are designed to incentivize cost reduction and quality improvement, but there are no requirements established for evaluating the outcomes of the Medicare populations.

OBJECTIVE

To examine whether participation in the Medicare Bundled Payments for Care Improvement Advanced (BPCI-A) program was associated with narrowing or widening of Black and White racial inequities in outcomes and access.

DESIGN, SETTING, AND PARTICIPANTS

Retrospective cohort alternative payment models on equity and quality for disadvantaged populations were studied between April 6, 2021, and August 28, 2022, in US hospitals. Black and White Medicare beneficiaries admitted for any of the 29 inpatient conditions in the BPCI-A program between January 1, 2017, and September 31, 2019, were included.

EXPOSURES

BPCI-A participation implemented in 2018.

MAIN OUTCOMES AND MEASURES

Ninety-day readmission and mortality, healthy days at home, and proportion of Black patients hospitalized. Segmented regression models were used to examine quarterly changes in slopes for each outcome.

RESULTS

The sample included 6 690 336 episodes (6 019 359 White patients, 670 977 Black patients). The population comprised approximately 43% men, 57% women, 17% individuals younger than 65 years, 47% between ages 65 and 80 years, and 36% older than 80 years. Prior to implementation of the BPCI-A program, compared with episodes for White patients, Black patients had higher 90-day readmissions (36.3% vs 29.6%), similar 90-day mortality (12.3% vs 13.3%), and fewer healthy days at home (mean, 68.5 vs 69.5 days). BPCI-A participation was not associated with significant changes in the racial gap in readmissions but was associated with a greater gain in heathy days at home (differences by race, -0.07 days per quarter; 95% CI, -0.12 to -0.01 days per quarter). Among Black patients admitted to BPCI-A hospitals vs controls, healthy days at home increased by 0.09 more days/episode per quarter (95% CI, 0.02-0.17 days/episode per quarter). The proportion of Black patients decreased similarly at BPCI-A and control hospitals.

CONCLUSIONS AND RELEVANCE

In this cohort study, BPCI-A participation was not associated with improvements in racial inequities in clinical outcomes. Black patients in BPCI-A had a slight gain in healthy days at home; there were no changes in access. The findings of this study suggest that more needs to be done if payment policy reform is going to be part of the efforts to address glaring racial inequities in health care quality and outcomes. These findings support a need for payment policy reform specifically targeting equity-enhancing programs.

Association of Hospital Participation in Bundled Payments for Care Improvement Advanced With Medicare Spending and Hospital Incentive Payments

Importance

Bundled Payments for Care Improvement Advanced (BPCI-A) is a Centers for Medicare & Medicaid Services (CMS) initiative that aims to produce financial savings by incentivizing decreases in clinical spending. Incentives consist of financial bonuses from CMS to hospitals or penalties paid by hospitals to CMS.

Objective

To investigate the association of hospital participation in BPCI-A with spending, and to characterize hospitals receiving financial bonuses vs penalties.

Design, Setting, and Participants

Difference-in-differences and cross-sectional analyses of 4 754 139 patient episodes using 2013-2019 US Medicare claims at 694 participating and 2852 nonparticipating hospitals merged with hospital and market characteristics.

Exposures

BPCI-A model years 1 and 2 (October 1, 2018, through December 31, 2019).

Main Outcomes and Measures

Hospitals' per-episode spending, CMS gross and net spending, and the incentive allocated to each hospital.

Results

The study identified 694 participating hospitals. The analysis observed a -$175 change in mean per-episode spending (95% CI, -$378 to $28) and an aggregate spending change of -$75.1 million (95% CI, -$162.1 million to $12.0 million) across the 428 670 episodes in BPCI-A model years 1 and 2. However, CMS disbursed $354.3 million (95% CI, $212.0 million to $496.0 million) more in bonuses than it received in penalties. Hospital participation in BPCI-A was associated with a net loss to CMS of $279.2 million (95% CI, $135.0 million to $423.0 million). Hospitals in the lowest quartile of Medicaid days received a mean penalty of $0.41 million; (95% CI, $0.09 million to $0.72 million), while those in the highest quartile received a mean bonus of $1.57 million; (95% CI, $1.09 million to $2.08 million). Similar patterns were observed for hospitals across increasing quartiles of Disproportionate Share Hospital percentage and of patients from racial and ethnic minority groups.

Conclusions and Relevance

Among US hospitals measured between 2013 and 2019, participation in BPCI-A was significantly associated with an increase in net CMS spending. Bonuses accrued disproportionately to hospitals providing care for marginalized communities.