Two-Year Evaluation of Mandatory Bundled Payments for Joint Replacement

Barnett, Michael L.; Wilcock, Andrew; McWilliams, J. Michael; Epstein, Arnold M.; Maddox, Karen E. Joynt; Orav, E. John; Grabowski, David C.; Mehrotra, Ateev

doi:10.1056/nejmsa1809010

Cited by 240 publications

(263 citation statements)

References 20 publications

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“…From Barnett and colleagues’ evaluation22 of the mandatory bundled payments for joint replacement using Medicare claims data, it is reassuring that no increase in complications were noted, despite reductions in use of post-acute care facilities. Ongoing questions regarding this type of programme involve their impact on domains important to patients not yet captured by Medicare data (eg, functional status, pain), as well as the Medicare beneficiary’s potential increased out-of-pocket medical expenses for services like physical therapy and wound care delivered in the outpatient setting 34…”

Section: Discussionmentioning

confidence: 99%

“…To assess the CJR’s impact, Barnett and colleagues22 compared the Medicare spending per episode and postsurgical complication rates for 803 ‘treatment’ hospitals in the areas mandated to participate in CJR compared with 962 hospitals from ‘control’ areas. Hospitals in both areas showed decreases in spending.…”

Section: Two-year Evaluation Of Mandatory Bundled Payments For Joint mentioning

confidence: 99%

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Quality & safety in the literature: July 2019

2019

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Section: Discussionmentioning

confidence: 99%

Section: Two-year Evaluation Of Mandatory Bundled Payments For Joint mentioning

confidence: 99%

Quality & safety in the literature: July 2019

2019

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“…In this study, we examined changes in spending and clinical outcomes for frail and nonfrail patients who were hospitalized for one of five common medical bundles under BPCI: congestive heart failure (CHF), pneumonia, chronic obstructive pulmonary disease (COPD), sepsis, and acute myocardial infarction (AMI)—or major joint replacement of the lower extremity (MJRLE). These conditions were among the most commonly chosen conditions in BPCI, and the overall impact of BPCI on patients with these conditions has been previously documented …”

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confidence: 87%

How Do Frail Medicare Beneficiaries Fare Under Bundled Payments?

Maddox

Orav

Zheng

et al. 2019

J American Geriatrics Society

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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

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“…Clarifying the impact of Medicare's copayment policy on SNF length of stay and on patient outcomes will help inform payment policy around SNF care and health care policies aimed at optimizing patient outcomes while constraining costs. This is particularly important in the setting of recent payment reforms that target postacute care and have been associated with both declines in SNF utilization and shorter SNF stays . Our objective was therefore to investigate the relationship between Medicare's SNF copayment policy and SNF length of stay and also between patient outcomes and Medicare costs.…”

Section: Introductionmentioning

confidence: 99%

The impact of Medicare copayments for skilled nursing facilities on length of stay, outcomes, and costs

Werner

Konetzka

et al. 2019

Health Services Research

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Objective To investigate the impact of Medicare's skilled nursing facility (SNF) copayment policy, with a large increase in the daily copayment rate on the 20th day of a benefit period, on length of stay, patient outcomes, and costs. Data Sources and Study Setting Retrospective cohort study from 2012 to 2016 using Medicare claims and SNF assessment data, including SNF admissions for Medicare fee‐for‐service beneficiaries. Study Design We first estimate how changes in Medicare's SNF copayment on the 21st day of a patient's benefit period affect length of SNF stay. We then use benefit day on admission as an instrumental variable to estimate the impact of SNF length of stay related to the copayment policy on readmission and Medicare payment. Principal Findings From 2012 to 2016, we examined 291 134 SNF admissions. Higher benefit day on SNF admission was strongly associated with shorter SNF stays. A 1‐day shorter SNF stay was associated with higher readmission rate within 30 days of hospital discharge (1.5 percentage points; 95% CI 1.4‐1.6, P < .001) and within 30 days of SNF discharge (0.9 percentage points; 95% CI 0.8‐1.0), lower total Medicare payment for the 90‐day episode after hospital discharge ($396; 95% CI 361‐431, P < .001), but $179 higher payment for the 90 days after SNF discharge (95% CI 149‐210, P < .001), offsetting the lower payment for the shorter index SNF stay. Conclusions Medicare's SNF copayment policy is associated with shorter lengths of stay and worse patient outcomes, suggesting the copayment policy has unintended and negative effects on patient outcomes.

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Two-Year Evaluation of Mandatory Bundled Payments for Joint Replacement

Cited by 240 publications

References 20 publications

Quality & safety in the literature: July 2019

Quality & safety in the literature: July 2019

How Do Frail Medicare Beneficiaries Fare Under Bundled Payments?

The impact of Medicare copayments for skilled nursing facilities on length of stay, outcomes, and costs

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