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

Impact of Medicare eligibility on informal caregiving for surgery and stroke

OBJECTIVE

To assess whether the intensity of family and friend care changes after older individuals enroll in Medicare at age 65.

DATA SOURCES

Health and Retirement Study survey data (1998-2018).

STUDY DESIGN

We compared informal care received by patients hospitalized for stroke, heart surgery, or joint surgery and who were stratified into propensity-weighted pre- and post-Medicare eligibility cohorts. A regression discontinuity design compared the self-reported likelihood of any care receipt, weekly hours of overall informal care, and intensity of informal care (hours among those receiving any care) at Medicare eligibility.

DATA COLLECTION

Not applicable.

PRINCIPAL FINDINGS

A total of 2270 individuals were included; 1674 (73.7%) stroke, 240 (10.6%) heart surgery, and 356 (15.7%) joint surgery patients. Mean (SD) care received was 20.0 (42.1) weekly hours. Of the 1214 (53.5%) patients who received informal care, the mean (SD) care receipt was 37.4 (51.7) weekly hours. Mean (SD) overall weekly care received was 23.4 (45.5), 13.9 (35.8), and 7.8 (21.6) for stroke, heart surgery, and joint surgery patients, respectively. The onset of Medicare eligibility was associated with a 13.6 percentage-point decrease in the probability of informal care received for stroke patients (p = 0.003) but not in the other acute care cohorts. Men had a 16.8 percentage-point decrease (p = 0.002) in the probability of any care receipt.

CONCLUSIONS

Medicare coverage was associated with a substantial decrease in family and friend caregiving use for stroke patients. Informal care may substitute for rather than complement restorative care, given that Medicare is known to expand the use of postacute care. The observed spillover effect of Medicare coverage on informal caregiving has implications for patient function and caregiver burden and should be considered in episode-based reimbursement models that alter professional rehabilitative care intensity.

Bundled Payments for Care Improvement Efficacy Across 3 Common Operations

OBJECTIVE

The aim of this study was to evaluate associations between hospital participation in Bundled Payments for Care Improvement (BPCI) and 30-day total episode and post-acute care spending for lower extremity joint replacement (LEJR), coronary artery bypass graft (CABG), and colec-tomy.

SUMMARY BACKGROUND DATA

BPCI has been shown to reduce spending for LEJR episodes largely from reductions in post-acute care. However, BPCI efficacy in other common elective procedures, including CABG and colec-tomy, remains unclear. It is also unknown whether post-acute care spending reductions drive total spending reductions outside of LEJR.

METHODS

Retrospective cohort study using 100% Medicare claims data to identify BPCI (312 total) and non-BPCI (1,977 total) acute care hospitals from January 1, 2010 to November 30, 2016 with Medicare-enrolled patient discharges for at least one of the following BPCI episodes: LEJR (454,369 episodes), CABG (107,307 episodes), or colectomy (73,717 episodes). Along with difference-in-differences (DiD) analysis, we constructed generalized synthetic controls in the presence of nonparallel trends to estimate associations between BPCI participation and 30-day total and post-acute care spending.

RESULTS

DiD estimates indicated reduced spending for LEJR (-$541.6 [95% confidence interval (CI): -718.0 to -365.3]) and colectomy (-$582.1 [95% CI: -927.3 to -236.8]) but not CABG (-$268.9 [95% CI: -831.5 to 293.7]). Generalized synthetic control estimates indicated reduced spending for LEJR (-$795.3 [95% CI: -10,22.1 to -582.2]) but not colectomy (-$251.3 [95% CI: -997.9 to 335.2]) or CABG (-$257.8 [95% CI: -10,24.6 to 414.8]).Post-acute care comprised 42.6% of LEJR spending reductions and 53.0% of colectomy spending reductions.

CONCLUSIONS

BPCI participation was associated with significant spending reductions for LEJR and colectomy but not CABG. We conclude that BPCI has episode-dependent efficacy, largely determined by post-acute care.

Post-Acute Care Use Associated with Medicare Shared Savings Program and Disparities

OBJECTIVES

Medicare Shared Savings Program (MSSP) was implemented in 2012, but the impact of the MSSP on institutional post-acute care (PAC) use, and by race/ethnicity and payer status is less studied. We studied the impact of hospital participation in the MSSP on institutional PAC use and variations by race/ethnicity and payer status among 3 Medicare patient groups: ischemic stroke, hip fracture, and elective total joint arthroplasty (TJA).

DESIGN

A retrospective analysis of 2010-2016 Medicare Provider Analysis and Review files.

SETTING AND PARTICIPANTS

Medicare fee-for-service patients originally admitted for ischemic stroke, hip fracture, or elective TJA in MSSP-participating hospitals or nonparticipating hospitals.

METHODS

Patient-level linear probability models with difference-in-differences approach were used to compare the changes in institutional PAC use in MSSP-participating hospitals with nonparticipating hospitals as well as to compare the changes in differences by race/ethnicity and payer status in institutional PAC use over time.

RESULTS

Hospital participation in MSSP was significantly associated with increased institutional PAC use for the ischemic stroke cohort by 1.5 percentage points [95% confidence interval (CI) 0.00-0.3, P < .05] compared with non-MSSP participating hospitals. Regarding variations by race/ethnicity and payer status, for the elective TJA patients, racial minority patients in MSSP-participating hospitals had 3.8 percentage points greater (95% CI 0.01-0.06, P < .01) in institutional PAC use than white patients. Also, for ischemic stroke cohort, dual-eligible patients in MSSP-participating hospitals had 2.0 percentage points greater (95% CI 0.00-0.04, P < .10) in institutional PAC use than Medicare-only patients.

CONCLUSIONS AND IMPLICATIONS

This study found that hospital participation in the MSSP was associated with slightly increased institutional PAC use for ischemic stroke Medicare patients. Also, compared to non-MSSP participating hospitals, MSSP-participating hospitals were more likely to discharge racial minority patients for elective TJA and dual-eligible patients for ischemic stroke to institutional PAC.

Life After BPCI: High Quality Total Knee and Hip Arthroplasty Care Can Still Exist Outside of a Bundled Payment Program

BACKGROUND

Concerns regarding target price methodology and financial penalties have led to withdrawal from Medicare bundled payment programs for total hip (THA) and knee arthroplasty (TKA), despite its early successful results. The purpose of this study was to determine whether there was any difference in patient comorbidities and outcomes following our institution's exit from the Bundled Payments for Care Improvement - Advanced (BPCI-A).

METHODS

We reviewed consecutive 2,737 primary TKA and 2,009 primary THA patients following our withdraw from BPCI-A January 1, 2020-March 30, 2021 and compared them to 1,203 TKA and 1,088 THA patients from October 1, 2018-August 2, 2019 enrolled in BPCI-A. We compared patient demographics, comorbidities, discharge disposition, complications, and 90-day readmissions. Multivariate analysis was performed to identify if bundle participation was associated with complications or readmissions.

RESULTS

Post-bundle TKA had shorter length of stay (1.4 vs 1.8 days, P < .001). Both TKA and THA patients were significantly less likely to be discharged to a rehabilitation facility (5.6% vs 19.2%, P < .001 and 6.0% vs 10.0%, P < .001, respectively). Controlling for confounders, post-bundle TKA had lower complications (OR = 0.66, 95% CI 0.45-0.98, P = .037) but no difference in 90-day readmission (OR = 0.80, 95% CI 0.55-1.16, P = .224).

CONCLUSIONS

Since leaving BPCI-A, we have maintained high quality THA care and improved TKA care with reduced complications and length of stay under a fee-for-service model. Furthermore, we have lowered rehabilitation discharge for both TKA and THA patients. CMS should consider partnering with high performing institutions to develop new models for risk sharing.

Getting to 100%: Research Priorities and Unanswered Questions to Inform the US Debate on Universal Health Insurance Coverage

A majority of Americans favor universal health insurance, but there is uncertainty over how best to achieve this goal. Whatever the insurance design that is implemented, additional details that must be considered include breadth of services covered, restrictions and limits on volumes of services, cost-sharing for individuals, and pricing. In the hopes that research can inform this ongoing debate, we review evidence supporting different models for achieving universal coverage in the US and identify areas where additional research and stakeholder input is needed. Key areas in need of further research include how care should be organized, how costs can be reduced, and what healthcare services universal insurance should cover.

Predictors of Success in the Bundled Payments for Care Improvement Program

BACKGROUND

Hospitals participating in Medicare's Bundled Payments for Care Improvement (BPCI) program were incented to reduce Medicare payments for episodes of care.

OBJECTIVE

To identify factors that influenced whether or not hospitals were able to save in the BPCI program, how the cost of different services changed to produce those savings, and if "savers" had lower or decreased quality of care.

DESIGN

Retrospective cohort study.

PARTICIPANTS

BPCI-participating hospitals.

MAIN MEASURES

We designated hospitals that met the program goal of decreasing costs by at least 2% from baseline in average Medicare payments per 90-day episode as "savers." We used regression models to determine condition-level, patient-level, hospital-level, and market-level characteristics associated with savings.

KEY RESULTS

In total, 421 hospitals participated in BPCI, resulting in 2974 hospital-condition combinations. Major joint replacement of the lower extremity had the highest proportion of savers (77.6%, average change in payments -$2235) and complex non-cervical spinal fusion had the lowest (22.2%, average change +$8106). Medical conditions had a higher proportion of savers than surgical conditions (11% more likely to save, P=0.001). Conditions that were mostly urgent/emergent had a higher proportion of savers than conditions that were mostly elective (6% more likely to save, P=0.007). Having higher than median costs at baseline was associated with saving (OR: 3.02, P<0.001). Hospitals with more complex patients were less likely to save (OR: 0.77, P=0.003). Savings occurred across both inpatient and post-acute care, and there were no decrements in clinical care associated with being a saver.

CONCLUSIONS

Certain conditions may be more amenable than others to saving under bundled payments, and hospitals with high costs at baseline may perform well under programs which use hospitals' own baseline costs to set targets. Findings may have implications for the BPCI-Advanced program and for policymakers seeking to use payment models to drive improvements in care.

Demand Matching and Site of Care: High-Cost Facilities Do Not Improve Short-term Quality Metrics Following Total Hip and Knee Arthroplasty

With increased emphasis on improving value in total hip arthroplasty (THA) and total knee arthroplasty (TKA) care, concerns exist about whether variability in hospital costs between facilities is justified. The purpose of this study was to compare index facility reimbursement among hospitals and short-term outcomes for patients undergoing primary THA and TKA. We queried a single private insurer's claims data, identifying all patients undergoing THA or TKA from 2015 to 2017 performed by 25 surgeons across 16 hospitals within our institution. Hospitals were divided into high- and low-cost facilities based on mean index reimbursement. We compared comorbidities, episode-of-care costs, and short-term outcomes between facilities and performed multivariate analyses. Of 2963 procedures, 1305 (44%) were performed at higher-cost hospitals. Higher-cost facilities had higher mean index reimbursement ($40,597 vs $26,781, P<.0001) and higher mean Charlson Comorbidity Index (CCI; 0.32 vs 0.24, P=.0029), but no difference in complications (2.2% vs 1.8%, P=.3955) or readmissions (2.2% vs 1.5%, P=.1490). On multivariate analyses, higher-cost facility increased index reimbursement by $13,780 (95% CI, $13,489-$14,071, P<.0001) and discharge to facility risk (odds ratio [OR], 3.2; 95% CI, 1.9-5.4; P<.0001), but not complication (OR, 1.2; 95% CI, 0.7-2.0; P=.5983) or readmission (OR, 1.5; 95% CI, 0.9-2.6; P=.1474) risks. Shifting 25% of patients with a CCI of 0 from higher- to lower-cost centers would have decreased inpatient facility costs by an estimated $3,582,784. Wide variability exists between hospital facility costs for THA and TKA without differences in short-term outcomes. Demand matching healthier patients to lower-cost facilities may significantly lower the overall procedural costs of THA and TKA. [Orthopedics. 2022;45(1):19-24.].

Skilled Nursing Facility Participation in a Voluntary Medicare Bundled Payment Program: Association With Facility Financial Performance

IMPORTANCE

Model 3 of the Bundled Payments for Care Improvement (BPCI) is an alternative payment model in which an entity takes accountability for the episode costs. It is unclear how BPCI affected the overall skilled nursing facility (SNF) financial performance and the differences between facilities with differing racial/ethnic and socioeconomic status (SES) composition of the residents.

OBJECTIVE

The objective of this study was to determine associations between BPCI participation and SNF finances and across-facility differences in SNF financial performance.

DESIGN, SETTING, AND PARTICIPANTS

A longitudinal study spanning 2010-2017, based on difference-in-differences analyses for 575 persistent-participation SNFs, 496 dropout SNFs, and 13,630 eligible nonparticipating SNFs.

MAIN OUTCOME MEASURES

Inflation-adjusted operating expenses, revenues, profit, and profit margin.

RESULTS

BPCI was associated with reductions of $0.63 million in operating expenses and $0.57 million in operating revenues for the persistent-participation group but had no impact on the dropout group compared with nonparticipating SNFs. Among persistent-participation SNFs, the BPCI-related declines were $0.74 million in operating expenses and $0.52 million in operating revenues for majority-serving SNFs; and $1.33 and $0.82 million in operating expenses and revenues, respectively, for non-Medicaid-dependent SNFs. The between-facility SES gaps in operating expenses were reduced (differential difference-in-differences estimate=$1.09 million). Among dropout SNFs, BPCI showed mixed effects on across-facility SES and racial/ethnic differences in operating expenses and revenues. The BPCI program showed no effect on operating profit measures.

CONCLUSIONS

BPCI led to reduced operating expenses and revenues for SNFs that participated and remained in the program but had no effect on operating profit indicators and mixed effects on SES and racial/ethnic differences across SNFs.

Alternative Payment Models and Associations With Stroke Outcomes, Spending, and Service Utilization: A Systematic Review

Stroke contributes an estimated $28 billion to US health care costs annually, and alternative payment models aim to improve outcomes and lower spending over fee-for-service by aligning economic incentives with high value care. This systematic review evaluates historical and current evidence regarding the impacts of alternative payment models on stroke outcomes, spending, and utilization. Included studies evaluated alternative payment models in 4 categories: pay-for-performance (n=3), prospective payments (n=14), shared savings (n=5), and capitated payments (n=14). Pay-for-performance models were not consistently associated with improvements in clinical quality indicators of stroke prevention. Studies of prospective payments suggested that poststroke spending was shifted between care settings without consistent reductions in total spending. Shared savings programs, such as US Medicare accountable care organizations and bundled payments, were generally associated with null or decreased spending and service utilization and with no differences in clinical outcomes following stroke hospitalizations. Capitated payment models were associated with inconsistent effects on poststroke spending and utilization and some worsened clinical outcomes. Shared savings models that incentivize coordination of care across care settings show potential for lowering spending with no evidence for worsened clinical outcomes; however, few studies evaluated clinical or patient-reported outcomes, and the evidence, largely US-based, may not generalize to other settings.

Trends in Discharge Disposition Following Hepatectomy for Hepatocellular Carcinoma Among Medicare Beneficiaries

BACKGROUND

Post-acute care (PAC) services can include home healthcare, long-term care hospitals, and skilled nursing facilities. We sought to define factors associated with PAC discharge disposition among Medicare beneficiaries who underwent hepatectomy for hepatocellular carcinoma (HCC).

METHODS

Data for Medicare beneficiaries with a diagnosis of HCC and who underwent a hepatectomy between 2004 and 2015 were retrieved from the SEER-Medicare database. Discharge disposition was defined as routine (HSC: discharged to home) or non-routine (SNF/ICF, discharged to skilled nursing/intermediate care facilities, or HHA, discharge to home with home health agency). The Cochran-Mantel-Haenszel test and multivariable logistic regression were used to assess trends in discharge disposition.

RESULTS

Among 1305 patients, the median patient age at diagnosis was 72 years (IQR: 68-76). Approximately 4 in 5 patients were discharged to HSC (77.4%; n = 1010). The odds of a non-routine discharge decreased by 7.0% annually from 2004 to 2015 (OR_trend, 0.93; 95%CI, 0.89-0.97; p_trend = 0.001). Several factors were associated with non-routine discharge, including patient age (OR 1.06, 95%CI 1.04-1.09) and longer LOS (OR 1.07, 95%CI 1.05-1.10). In contrast, patients who had a minor hepatectomy (OR 0.69, 95%CI 0.52-0.93) at a teaching hospital (OR 0.63, 95%CI 0.45-0.89) had lower odds of a non-routine discharge (all P < 0.05). HSC discharge increased over time (2004-2007 (n = 205, 68.1%) vs. 2008-2011 (n = 330, 77.8%) vs. 2012-2015 (n = 475, 81.9%); p_trend < 0.001). Over the same time period, there was a decreasing trend in 90-day readmission (2004-2007 (n = 91, 30.2%) vs. 2008-2011 (n = 107, 25.2%) vs. 2012-2015 (n = 129, 22.2%); p_trend = 0.03).

CONCLUSION

Utilization of PAC services following hepatic resection of HCC decreased by 57.0% between 2004 and 2015. These data highlight that decreased PAC utilization was not generally associated with higher readmission rates following resection of HCC.

Why and How to Demonstrate the Value of Rehabilitation Services

The health care delivery landscape in the United States is changing as payment models consider both costs and health outcomes, which are key components of value in health care. Without evidence about the effectiveness and costs of rehabilitation interventions, it is difficult to judge the value of rehabilitation interventions. Understanding the short- and long-term costs associated with implementing a rehabilitation intervention and the intervention's cost-effectiveness compared with other alternatives is critical to supporting decision-making by policymakers, health care administrators, and other decision makers. This article describes the policy context for considering the costs and outcomes of postacute care and rehabilitation interventions, introduces methods for assessing the value of rehabilitation interventions, and summarizes the challenges and opportunities associated with applying value measurement to rehabilitation services. Assessing the value of rehabilitation interventions is critical as we continue to identify, implement, and sustain evidence-based interventions that promote the health and function of people with disabilities.

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

BACKGROUND

The Center for Medicare and Medicaid Innovation launched the Medicare Bundled Payments for Care Improvement-Advanced (BPCI-A) program for hospitals in October 2018. Information is needed about the effects of the program on health care utilization and Medicare payments.

METHODS

We conducted a modified segmented regression analysis using Medicare claims and including patients with discharge dates from January 2017 through September 2019 to assess differences between BPCI-A participants and two control groups: hospitals that never joined the BPCI-A program (nonjoining hospitals) and hospitals that joined the BPCI-A program in January 2020, after the conclusion of the intervention period (late-joining hospitals). The primary outcomes were the differences in changes in quarterly trends in 90-day per-episode Medicare payments and the percentage of patients with readmission within 90 days after discharge. Secondary outcomes were mortality, volume, and case mix.

RESULTS

A total of 826 BPCI-A participant hospitals were compared with 2016 nonjoining hospitals and 334 late-joining hospitals. Among BPCI-A hospitals, the mean baseline 90-day per-episode Medicare payment was $27,315; the change in the quarterly trends in the intervention period as compared with baseline was -$78 per quarter. Among nonjoining hospitals, the mean baseline 90-day per-episode Medicare payment was $25,994; the change in quarterly trends as compared with baseline was -$26 per quarter (difference between nonjoining hospitals and BPCI-A hospitals, $52 [95% confidence interval {CI}, 34 to 70] per quarter; P<0.001; 0.2% of the baseline payment). Among late-joining hospitals, the mean baseline 90-day per-episode Medicare payment was $26,807; the change in the quarterly trends as compared with baseline was $4 per quarter (difference between late-joining hospitals and BPCI-A hospitals, $82 [95% CI, 41 to 122] per quarter; P<0.001; 0.3% of the baseline payment). There were no meaningful differences in the changes with regard to readmission, mortality, volume, or case mix.

CONCLUSIONS

The BPCI-A program was associated with small reductions in Medicare payments among participating hospitals as compared with control hospitals. (Funded by the National Heart, Lung, and Blood Institute.).

Savings and outcomes under Medicare's bundled payments initiative for skilled nursing facilities

BACKGROUND

Model 3 of Medicare's Bundled Payments for Care Improvement (BPCI) was a voluntary alternative payment model that held participating skilled nursing facilities (SNFs) accountable for 90-day costs of care. Its overall impact on Medicare spending and clinical outcomes is unknown.

METHODS

Retrospective cohort study using Medicare claims from 2012 to 2017. We used an interrupted time-series design to compare participating vs matched control SNFs on total 90-day Medicare payments and payment components (initial SNF stay, readmissions, and outpatient/clinician), case mix (volume, proportion Medicaid, proportion black, number of comorbidities), and clinical outcomes (90-day readmission, mortality and healthy days at home, and length of initial SNF stay), overall and among key subgroups with frailty or dementia, for 47 of the 48 conditions in the program (excluding major lower extremity joint replacement).

RESULTS

Our sample included 1001 participating and 3873 matched control SNFs. At baseline, total Medicare institutional payments were increasing at BPCI SNFs at a rate of $121 per episode per quarter; during the intervention period, payments decreased at a rate of -$398/episode/quarter. Among controls, payments were stable in the baseline period (+$17/episode/quarter) but decreased at -$424/episode/quarter during the intervention period, yielding a nonsignificant difference in slope changes of -$79/episode/quarter (95% confidence interval [CI] -$188, $31, p = 0.16). However, among patients with frailty, spending declined by $620/episode/quarter in the BPCI group, compared with $330/episode/quarter in the non-BPCI group, for a difference in slope changes of -$289 (95% CI -$482, -$96, p = 0.003). There were no differences in the change in slopes in case selection or clinical outcomes overall or in any clinical subgroup.

CONCLUSIONS

SNF participation in BPCI was associated with no overall differential change in total Medicare payments per episode, case selection, or clinical outcomes. Exploratory analyses revealed a decrease in Medicare payments in patients with frailty that may warrant further study.

Medicare bundles for arthroplasty : a journey back to fee for service?

AIMS

There is concern that aggressive target pricing in the new Bundled Payment for Care Improvement Advanced (BPCI-A) penalizes high-performing groups that had achieved low costs through prior experience in bundled payments. We hypothesize that this methodology incorporates unsustainable downward trends on Target Prices and will lead to groups opting out of BPCI Advanced in favour of a traditional fee for service.

METHODS

Using the Centers for Medicare and Medicaid Services (CMS) data, we compared the Target Price factors for hospitals and physician groups that participated in both BPCI Classic and BPCI Advanced (legacy groups), with groups that only participated in BPCI Advanced (non-legacy). With rebasing of Target Prices in 2020 and opportunity for participants to drop out, we compared retention rates of hospitals and physician groups enrolled at the onset of BPCI Advanced with current enrolment in 2020.

RESULTS

At its peak in July 2015, 342 acute care hospitals and physician groups participated in Lower Extremity Joint Replacement (LEJR) in BPCI Classic. At its peak in March 2019, 534 acute care hospitals and physician groups participated in LEJR in BPCI Advanced. In January 2020, only 14.5% of legacy hospitals and physician groups opted to stay in BPCI Advanced for LEJR. Analysis of Target Price factors by legacy hospitals during both programmes demonstrates that participants in BPCI Classic received larger negative adjustments on the Target Price than non-legacy hospitals.

CONCLUSION

BPCI Advanced provides little opportunity for a reduction in cost to offset a reduced Target Price for efficient providers, as made evident by the 85.5% withdrawal rate for BPCI Advanced. Efficient providers in BPCI Advanced are challenged by the programme's application of trend and efficiency factors that presumes their cost reduction can continue to decline at the same rate as non-efficient providers. It remains to be seen if reverting back to Medicare fee for service will support the same level of care and quality achieved in historical bundled payment programmes. Cite this article: Bone Joint J 2021;103-B(6 Supple A):119-125.

Integration Activities Between Hospitals and Skilled Nursing Facilities: A National Survey

OBJECTIVES

Increasing recognition of the adverse events older adults experience in post-acute care in skilled nursing facilities (SNFs) has led to multiple efforts to improve care integration between hospitals and SNFs. We sought to measure current care integration activities between hospitals and SNFs.

DESIGN

Cross-sectional survey.

SETTING AND PARTICIPANTS

A total of 500 randomly selected Medicare-certified SNFs in the United States in 2019. The survey inquired about 12 care integration activities with the 2 highest volume referring hospitals for each SNF.

METHODS

We collapsed survey responses into 5 categories of integration based on high correlations between the individual measures. These were: (1) formal integration (co-location or co-ownership); (2) informal integration (eg, formal affiliation, participation in SNF collaborative, shared pay for performance, or clinical leadership meetings between hospital and SNF); (3) shared quality/safety activities (eg, initiatives to improve medication safety or reduce hospital admission); (4) shared care coordinators; and/or (5) shared supervising clinicians. We then conducted multivariate regressions to examine associations between different care integration activities and hospital/SNF characteristics.

RESULTS

Our overall response rate was 53.0%, including 265 SNFs that represented 487 SNF-hospital pairs. Informal integration was most common (in 53.3% of pairs), whereas shared clinicians (43.0%), care coordinators (36.5%), shared quality/safety activities (35.1%), and formal integration (7.4%) were present in a minority. Hospital-SNF pairs had lower odds of being formally integrated if the SNF was for-profit compared with not-for-profit [odds ratio (OR) 0.11, 95% confidence interval (CI) 0.03-0.42, adjusted P = .04)] and higher odds of sharing quality improvement activities in metropolitan rather than rural areas (OR 4.06, 95% CI 1.80-9.17, adjusted P = .02) and in the Midwest compared with West (OR 2.95, 95% CI 1.44-6.06, adjusted P = .049).

CONCLUSIONS AND IMPLICATIONS

These findings raise important questions about what is driving variability in hospital-SNF integration activities, and which activities may be most effective for improving transitional care outcomes.

Late-week surgery and discharge to specialty care associated with higher costs and longer lengths of stay after elective lumbar laminectomy

OBJECTIVE

In a healthcare landscape in which costs increasingly matter, the authors sought to distinguish among the clinical and nonclinical drivers of patient length of stay (LOS) in the hospital following elective lumbar laminectomy-a common spinal surgery that may be reimbursed using bundled payments-and to understand their relationships with patient outcomes and costs.

METHODS

Patients ≥ 18 years of age undergoing laminectomy surgery for degenerative lumbar spinal stenosis within the Cleveland Clinic health system between March 1, 2016, and February 1, 2019, were included in this analysis. Generalized linear modeling was used to assess the relationships between the day of surgery, patient discharge disposition, and hospital LOS, while adjusting for underlying patient health risks and other nonclinical factors, including the hospital surgery site and health insurance.

RESULTS

A total of 1359 eligible patients were included in the authors' analysis. The mean LOS ranged between 2.01 and 2.47 days for Monday and Friday cases, respectively. The LOS was also notably longer for patients who were ultimately discharged to a skilled nursing facility (SNF) or rehabilitation center. A prolonged LOS occurring later in the week was not associated with greater underlying health risks, yet it nevertheless resulted in greater costs of care: the average total surgical costs for lumbar laminectomy were 20% greater for Friday cases than for Monday cases, and 24% greater for late-week cases than for early-week cases ultimately transferred to SNFs or rehabilitation centers. A Poisson generalized linear model fit the data best and showed that the comorbidity burden, surgery at a tertiary care center versus a community hospital, and the incidence of any postoperative complication were associated with significantly longer hospital stays. Discharge to home healthcare, SNFs, or rehabilitation centers, and late-week surgery were significant nonclinical predictors of LOS prolongation, even after adjusting for underlying patient health risks and insurance, with LOSs that were, for instance, 1.55 and 1.61 times longer for patients undergoing their procedure on Thursday and Friday compared to Monday, respectively.

CONCLUSIONS

Late-week surgeries are associated with a prolonged LOS, particularly when discharge is to an SNF or rehabilitation center. These findings point to opportunities to lower costs and improve outcomes associated with elective surgical care. Interventions to optimize surgical scheduling and perioperative care coordination could help reduce prolonged LOSs, lower costs, and, ultimately, give service line management personnel greater flexibility over how to use existing resources as they remain ahead of healthcare reforms.

Strategies for spinal surgery reimbursement: bundling in the working-age population

Introduction

Bundled payments for spine surgery, which is known for having high overall cost with wide variation, have been previously studied in older adults. However, there has been limited work examining bundled payments in working-age patients. We sought to identify the variation in the cost of spine surgery among working age adults in a large, national insurance claims database.

Methods

We queried the TRICARE claims database for all patients, aged 18–64, undergoing cervical and non-cervical spinal fusion surgery between 2012 and 2014. We calculated the case mix adjusted, price standardized payments for all aspects of care during the 60-, 90-, and 180-day periods post operation. Variation was assessed by stratifying Hospital Referral Regions into quintiles.

Results

After adjusting for case mix, there was significant variation in the cost of both cervical ($10,538.23, 60% of first quintile) and non-cervical ($20,155.59, 74%). Relative variation in total cost decreased from 60- to 180-days (63 to 55% and 76 to 69%). Index hospitalization was the primary driver of costs and variation for both cervical (1st-to-5th quintile range: $11,033–$19,960) and non-cervical ($18,565–$36,844) followed by readmissions for cervical ($0–$11,521) and non-cervical ($0–$13,932). Even at the highest quintile, post-acute care remained the lowest contribution to overall cost ($2070 & $2984).

Conclusions

There is wide variation in the cost of spine surgery across the United States for working age adults, driven largely by index procedure and readmissions costs. Our findings suggest that implementing episodes longer than the current 90-day standard would do little to better control cost variation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06112-0.

Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients

IMPORTANCE

The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown.

OBJECTIVE

To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs.

MAIN OUTCOME MEASURES

Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident.

RESULTS

The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities.

CONCLUSIONS

The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.

Association of Skilled Nursing Facility Participation in a Bundled Payment Model With Institutional Spending for Joint Replacement Surgery

Importance

Medicare recently concluded a national voluntary payment demonstration, Bundled Payments for Care Improvement (BPCI) model 3, in which skilled nursing facilities (SNFs) assumed accountability for patients' Medicare spending for 90 days from initial SNF admission. There is little evidence on outcomes associated with this novel payment model.

Objective

To evaluate the association of BPCI model 3 with spending, health care utilization, and patient outcomes for Medicare beneficiaries undergoing lower extremity joint replacement (LEJR).

Design, Setting, and Participants

Observational difference-in-difference analysis using Medicare claims from 2013-2017 to evaluate the association of BPCI model 3 with outcomes for 80 648 patients undergoing LEJR. The preintervention period was from January 2013 through September 2013, which was 9 months prior to enrollment of the first BPCI cohort. The postintervention period extended from 3 months post-BPCI enrollment for each SNF through December 2017. BPCI SNFs were matched with control SNFs using propensity score matching on 2013 SNF characteristics.

Exposures

Admission to a BPCI model 3-participating SNF.

Main Outcomes and Measures

The primary outcome was institutional spending, a combination of postacute care and hospital Medicare-allowed payments. Additional outcomes included other categories of spending, changes in case mix, admission volume, home health use, length of stay, and hospital use within 90 days of SNF admission.

Results

There were 448 BPCI SNFs with 18 870 LEJR episodes among 16 837 patients (mean [SD] age, 77.5 [9.4] years; 12 173 [72.3%] women) matched with 1958 control SNFs with 72 005 LEJR episodes among 63 811 patients (mean [SD] age, 77.6 [9.4] years; 46 072 [72.2%] women) in the preintervention and postintervention periods. Seventy-nine percent of matched BPCI SNFs were for-profit facilities, 85% were located in an urban area, and 85% were part of a larger corporate chain. There were no systematic changes in patient case mix or episode volume between BPCI-participating SNFs and controls during the program. Institutional spending decreased from $17 956 to $15 746 in BPCI SNFs and from $17 765 to $16 563 in matched controls, a differential decrease of 5.6% (-$1008 [95% CI, -$1603 to -$414]; P < .001). This decrease was related to a decline in SNF days per beneficiary (from 26.2 to 21.3 days in BPCI SNFs and from 26.3 to 23.4 days in matched controls; differential change, -2.0 days [95% CI, -2.9 to -1.1]). There was no significant change in mortality or 90-day readmissions.

Conclusions and Relevance

Among Medicare patients undergoing lower extremity joint replacement from 2013-2017, the BPCI model 3 was significantly associated with a decrease in mean institutional spending on episodes initiated by admission to SNFs. Further research is needed to assess bundled payments in other clinical contexts.

Learning and the "Early Joiner" Effect for Medical Conditions in Medicare's Bundled Payments for Care Improvement Program: Retrospective Cohort Study

BACKGROUND

Studies of medical conditions in the Bundled Payments for Care Improvement (BPCI) initiative did not show reductions in Medicare payments for the majority of conditions, but this could mask heterogeneity.

OBJECTIVE

To determine whether earlier enrollment and/or longer participation in BPCI were associated with performance.

DESIGN

We divided BPCI hospitals into wave 1 (joined 10/1/13, 1/1/14, or 4/1/14), wave 2 (joined 7/1/14, 10/1/14, 1/1/15, or 4/1/15), and wave 3 (joined 7/1/15, 10/1/15, or 1/1/16) and compared changes in Medicare payments for acute myocardial infarction, heart failure, pneumonia, sepsis, and chronic obstructive pulmonary disease between BPCI and matched controls in 6-month increments.

SUBJECTS

US hospitals.

MEASURES

Medicare payments.

RESULTS

There were 120 hospital-condition pairs in wave 1, 264 in wave 2, and 300 in wave 3. Wave 1 hospitals had similar savings to controls early in the program (0-6 mo difference in differences -$10, P=0.976; 6-12 mo +$295, P=0.441; 12-18 mo -$540, P=0.218; 18-24 mo -$485, P=0.259) but had greater savings than controls at 24-30 months (difference in differences -$663, P=0.035). Wave 2 (0-6 mo +$193, P=0.524; 6-12 mo -$183, P=0.489; 12-18 mo -$162, P=0.618) and wave 3 hospitals (0-6 mo +$79, P=0.753; 6-12 mo -$32, P=0.876) did not achieve significant savings at any time interval. There were no differential changes in patient outcomes over time.

CONCLUSIONS

Hospitals that joined BPCI earliest began to achieve savings at roughly 2 years of participation. These findings have implications for this and other alternative payment models.

Association of Discharge to Home vs Institutional Postacute Care With Outcomes After Lower Extremity Joint Replacement

IMPORTANCE

Changes in financial incentives have led to more patients being discharged home than to institutional forms of postacute care, such as skilled nursing facilities (SNFs), after elective lower extremity total joint replacement (LEJR).

OBJECTIVE

To evaluate the association of this change with hospital readmissions, surgical complications, and mortality.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used cross-temporal propensity-matching to identify 104 828 adult patients who were discharged home following LEJR between 2016 and 2018 (after changes in financial incentives) and 84 121 adult patients discharged to institutional forms of postacute care (eg, SNFs) between 2011 and 2013 (before changes in financial incentives). A difference-in-differences design was used to compare differences in outcomes between these groups to a propensity-matched group of patients discharged to institutional postacute care in both periods. Data were collected from Pennsylvania all-payer claims database, which includes all surgical procedures and hospitalizations across payers and hospitals in Pennsylvania. Data were analyzed between August 2019 and February 2020.

EXPOSURES

Type of postacute care (home, including home with home health vs institutional postacute care, including SNF, inpatient rehabilitation facilities, and long-term acute care hospitals).

MAIN OUTCOMES AND MEASURES

Main outcomes were 30- and 90-day hospital readmissions, LEJR complication rates, and mortality rates.

RESULTS

Of 189 949 patients, 113 981 (60.0%) were women, and 83 444 (43.9%) were aged 40 to 64 years. The rate of discharge home increased from 63.6% (54 097 of 85 121) in 2011 to 2013 to 78.4% (82 199 of 104 828) in 2016 to 2018. In the adjusted difference-in-differences comparison, matched patients discharged home in 2016 to 2018 had significantly lower 30-day (difference, -2.9%; 95% CI, -4.2% to -1.6%) and 90-day (difference, -3.9%; 95% CI, -5.8% to -2.0%) readmission rates compared with similar patients sent to institutional postacute care in 2011 to 2013. Surgical complication and mortality rates were unchanged. Results were similar across payers and across hospital bundled payment participation status.

CONCLUSIONS AND RELEVANCE

In this cohort study, increases in discharges home following LEJR surgery did not seem to be associated with increased harm during a period in which changes in financial incentives likely spurred observed changes in postacute care.

Effect of statewide reduction in extended care facility use after joint replacement on hospital readmission

BACKGROUND

Extended care facility use is a primary driver of variation in hospitalization-associated health care payments and is increasingly a focus for savings under episode-based payment. However, concerns remain that extended care facility limits could incur rising readmissions, emergency department use, or other costs. We analyzed the effects of a statewide value improvement initiative to decrease extended care facility use after lower extremity arthroplasty on extended care facility use, readmission, emergency department use, and payments.

METHODS

We performed a retrospective cohort study using complete claims from the Michigan Value Collaborative for patients undergoing lower extremity joint replacement. We compared the change in extended care facility use before (2012-2013) and after (2016-2017) the aforementioned statewide initiative with 90-day postacute care, readmission, and emergency department rates and payments using t tests.

RESULTS

Of the patients included, 68,537 underwent total knee arthroplasty; 27,131 underwent total hip arthroplasty. Statewide, extended care facility use and postacute care payments decreased (extended care facility: 27.5% before vs 18.1% after, payments: $4,999 vs $3,832, P < .0001) without increased readmission rates (8.0% vs 7.6%, P = .10) or payments ($1,087 vs $1,026, P = .14). Emergency department use increased (7.8% vs 8.9%, P < .0001). Per hospital, there was no association between extended care facility use change and readmission rate change (r = 0.05). Hospital change in extended care facility use ranged from +2.3% (no extended care facility decrease group) to -16.6% (large extended care facility decrease group) and was associated with lower total episode payments without differences in change in readmission rate/payments or emergency department use.

CONCLUSION

Despite decreased use of extended care facilities, there was no compensatory increase in readmission rate or payments. Reducing excess use of extended care facilities after joint replacement may be an important opportunity for savings in episode-based reimbursement.

Impact of Medicare's Bundled Payments Initiative on Patient Selection, Payments, and Outcomes for Percutaneous Coronary Intervention and Coronary Artery Bypass Grafting

BACKGROUND

The Center for Medicare and Medicaid Innovation launched the Bundled Payments for Care Initiative (BPCI) in 2013. Its effect on payments and outcomes for percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG) is unknown.

METHODS AND RESULTS

We used Medicare inpatient files to identify index admissions for PCI and CABG from 2013 through 2016 at BPCI hospitals and matched control hospitals and difference in differences models to compare the 2 groups. Our primary outcome was the change in standardized Medicare-allowed payments per 90-day episode. Secondary outcomes included changes in patient selection, discharge to postacute care, length of stay, emergency department use, readmissions, and mortality. Forty-two hospitals joined BPCI for PCI and 46 for CABG. There were no differential changes in patient selection between BPCI and control hospitals. Baseline Medicare payments per episode for PCI were $20 164 at BPCI hospitals and $19 955 at control hospitals. For PCI, payments increased at both BPCI and control hospitals during the intervention period, such that there was no significant difference in differences (BPCI hospitals +$673, P=0.048; control hospitals +$551, P=0.022; difference in differences $122, P=0.768). For CABG, payments at both BPCI and control hospitals decreased during the intervention period (BPCI baseline, $36 925, change -$2918, P<0.001; control baseline, $36 877, change -$2618, P<0.001; difference in differences, $300; P=0.730). For both PCI and CABG, BPCI participation was not associated with changes in mortality, readmissions, or length of stay. Among BPCI hospitals, emergency department use differentially increased for patients undergoing PCI and decreased for patients undergoing CABG.

CONCLUSIONS

Participation in episode-based payment for PCI and CABG was not associated with changes in patient selection, payments, length of stay, or clinical outcomes.

High-Quality Skilled Nursing Facilities Are Associated With Decreased Episode-of-Care Costs Following Total Hip and Knee Arthroplasty

BACKGROUND

With the increasing popularity of alternative payment models following total hip (THA) and knee arthroplasty (TKA), efforts have focused on reducing post-acute care (PAC) costs, particularly patients discharged to skilled nursing facilities (SNFs). The purpose of this study is to determine if preferentially discharging patients to high-quality SNFs can reduce bundled payment costs for primary THA and TKA.

METHODS

At our institution, a quality improvement initiative for SNFs was implemented at the start of 2017, preferentially discharging patients to internally credentialed facilities, designated by several quality measures. Claims data from Centers for Medicare and Medicaid Services were queried to identify patients discharged to SNF following primary total joint arthroplasty. We compared costs and outcomes between patients discharged to credentialed SNF sites and those discharged to other sites.

RESULTS

Between 2015 and 2018, of a consecutive series of 8778 primary THA and TKA patients, 1284 (14.6%) were discharged to an SNF. Following initiation of the program, 498 patients were discharged to an SNF, 301 (60.4%) of which were sent to a credentialed facility. Patients at credentialed facilities had significantly lower SNF costs ($11,184 vs $8198, P < .0001), PAC costs ($18,952 vs $15,148, P < .0001), and episode-of-care costs ($34,557 vs $30,831, P < .0001), with no difference in readmissions (10% vs 12%, P = .33) or complications (8% vs 6%, P = .15). Controlling for confounding variables, being discharged to a credentialed facility decreased SNF costs by $1961 (P = .0020) and PAC costs by $3126 (P = .0031) per patient.

CONCLUSION

Quality improvement efforts through partnership with selective SNFs can significantly decrease PAC costs for patients undergoing primary THA and TKA.

Trends in Postacute Care Use and Outcomes After Hip and Knee Replacements in Dual-Eligible Medicare and Medicaid Beneficiaries, 2013-2016

IMPORTANCE

Several Medicare alternative payment models were implemented in recent years, but their implications for socioeconomic gaps in postacute care (PAC) are unknown.

OBJECTIVES

To determine the longitudinal trends in PAC use and outcomes after hip and knee replacements and in gaps among 3 groups: Medicare-only patients, dual-eligible patients with full Medicaid benefits, and dual-eligible patients with partial Medicaid benefits.

DESIGN, SETTING, AND PARTICIPANTS

A cohort study was conducted of PAC use and outcomes among Medicare fee-for-service patients undergoing hip or knee replacement surgery from January 1, 2013, to December 31, 2016, in approximately 3000 hospitals, using Medicare claims, assessment, hospital, and skilled nursing facility (SNF) files. Statistical analysis was performed from October 1, 2018, to December 17, 2019.

MAIN OUTCOMES AND MEASURES

Risk-adjusted differences among dual-eligible groups in institutional PAC use (SNF, inpatient rehabilitation, or long-term hospital care), readmission rate, and payment for readmissions; for patients discharged to a SNF, risk-adjusted differences in SNF quality measured by star ratings, proportion successfully discharged to the community, proportion transitioned to long-stay residence, and SNF length of stay and payments.

RESULTS

The sample included 1 302 256 patients (837 256 women [64.3%]; mean [SD] age, 75.4 [7.2] years) who underwent joint replacement. The proportion of patients discharged to institutional PAC and the 30-day and 90-day readmission rates decreased for all 3 groups during the period from 2013 to 2016. In 2013, institutional PAC use was 43.7% (95% CI, 43.5%-43.9%) for Medicare-only patients (n = 1 182 555), 70.1% (95% CI, 69.4%-70.8%; n = 60 461) for dual-eligible patients with full benefits, and 70.3% (95% CI, 69.6%-71.0%; n = 59 240) for dual-eligible patients with partial benefits; in 2016, the rates decreased to 32.5% (95% CI, 32.4%-32.7%) for Medicare-only patients, 62.3% (95% CI, 61.5%-63.0%) for dual-eligible patients with full benefits, and 61.5% (95% CI, 60.7%-62.3%) for dual-eligible patients with partial benefits. Among patients discharged to SNFs, outcomes remained flat over time. For example, the proportion of patients successfully discharged to the community remained at 80.5% (95% CI, 80.4%-80.7%) for Medicare-only patients, 59.8% (95% CI, 59.3%-60.3%) for dual-eligible patients with full benefits, and 50.0% (95% CI, 49.4%-50.5%) for dual-eligible patients with partial benefits. Multivariable analyses with adjustment for patient, hospital (or SNF), and geographical covariates suggested maintained or enlarged gaps in all outcomes.

CONCLUSIONS AND RELEVANCE

This study suggests that, during the period from 2013 to 2016, Medicare patients undergoing hip or knee replacement showed reduced institutional PAC use, reduced readmissions, and, among those discharged to SNFs, roughly unchanged outcomes. However, dual-eligible patients, especially those with partial Medicaid benefits, had persistently worse outcomes than Medicare-only patients.

How Do Frail Medicare Beneficiaries Fare Under Bundled Payments?

BACKGROUND/OBJECTIVES

Bundled payments are an alternative payment model in which a hospital takes accountability for the costs of a 90-day episode of care. Such models are meant to improve care through better coordination across care settings, but could have adverse consequences for frail adults if they lead to inappropriate cuts in necessary post-acute care.

DESIGN

Retrospective claims-based analysis of hospitals' first year of participation in Medicare's Bundled Payments for Care Improvement (BPCI) program.

SETTING

US hospitals.

PARTICIPANTS

A total of 641 146 Medicare beneficiaries admitted to 688 BPCI programs and 1276 matched control hospitals for myocardial infarction, heart failure, pneumonia, sepsis, chronic obstructive pulmonary disease, or major joint replacement of the lower extremity in 2012 to 2016.

INTERVENTION

Participation in BPCI.

MEASUREMENTS

Proportion of patients in each quartile of a validated claims-based frailty index, total and setting-specific standardized Medicare payments per episode, days at home, 90-day readmissions, and 90-day mortality.

RESULTS

Higher levels of frailty were associated with higher Medicare payments and worse clinical outcomes (for the medical composite, costs per episode were $11 921, $17 348, $22 828, and $29 157 across frailty quartiles; days at home were 70.1, 60.4, 54.3, and 51.5; 90-day readmission rates were 16.0%, 27.0%, 38.2%, and 50.9%; and 90-day mortality rates were 15.4%, 22.5%, 25.1%, 21.3%); patterns were similar for joint replacement. Under the BPCI program, there was no differential change in the proportion of highly frail patients at BPCI vs control hospitals. There were also no differential deleterious changes in payments or clinical outcomes for frail relative to nonfrail patients at BPCI vs non-BPCI hospitals.

CONCLUSION

While frail patients had higher costs and worse outcomes in general, there was no evidence of changes in access or worsening clinical outcomes in BPCI hospitals for frail patients relative to the nonfrail in hospitals' first year of participation in the program. These findings may be reassuring for policy makers and clinical leaders. J Am Geriatr Soc 67:2245-2253, 2019.

Medicare's bundled payment model did not change skilled nursing facility discharge patterns

OBJECTIVES

To evaluate whether participation in Medicare's voluntary Bundled Payments for Care Improvement (BPCI) model was associated with changes in discharge referral patterns to skilled nursing facilities (SNFs), specifically number of SNF partners and discharge concentration.

STUDY DESIGN

Retrospective observational study using difference-in-differences analysis.

METHODS

We used Medicare claims data from 2010 to 2015 to identify admissions for lower joint replacement surgery and the following medical conditions: congestive heart failure, renal failure, sepsis, pneumonia, urinary tract and kidney infections, chronic obstructive pulmonary disease, and stroke. We used difference-in-differences analyses to assess changes in discharge patterns among BPCI-participating hospitals compared with matched control hospitals.

RESULTS

Our analytic sample included 3078 acute care hospitals and 14,866 Medicare-certified SNFs in the United States, encompassing more than 47 million hospital discharges. Of these hospitals, 416 participated in BPCI, with the majority selecting into joint replacement episodes (n = 295). BPCI participation was not associated with any change in number of SNF partners (increase by 0.8 SNFs among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -0.2 to 1.9; P = .11) or in discharge concentration (increase in Herfindahl-Hirschman Index of 0.2 among BPCI hospitals relative to non-BPCI hospitals; 95% CI, -68.7 to 69.1; P = .36). Results did not vary across clinical conditions and were robust across duration of BPCI participation and with different comparison groups.

CONCLUSIONS

Hospital participation in BPCI was not associated with changes in the number of SNF partners or in discharge concentration relative to non-BPCI hospitals. More research is needed to understand how hospitals are responding to bundled payment incentives and specific practices that contribute to improvements in cost and quality.