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

Bundled payments, in which services provided around a care episode are linked together, are being tested under Medicare's Bundled Payments for Care Improvement (BPCI) program. Reducing post-acute care (PAC) is critical under bundled payment, but little is known about whether this is done through provider selection or consolidation, and whether particular patterns of changes in PAC are associated with success under the program. To characterize patterns of change in PAC under lower-extremity joint replacement episodes in BPCI. Retrospective difference-in-differences study. US Medicare, 2013 to 2015. A total of 264 US hospitals participating in BPCI for lower-extremity joint replacement and matched controls. Participation in BPCI. Use and duration of institutional PAC (proportion discharged to a skilled nursing facility, an inpatient rehabilitation facility, and a long-term care hospital), dispersion of PAC (proportion of discharges to commonly used providers), and quality of PAC (Star Ratings, readmission rates, length of stay, and nurse staffing); part A Medicare payments. BPCI participants decreased the use and duration of institutional PAC compared to controls: overall institutional PAC declined 4.4% in BPCI hospitals vs 2.1% in non-BPCI hospitals (difference = -2.2%; P = .033), and duration decreased by 1.6 days in BPCI hospitals compared to 0.0 days in non-BPCI hospitals (difference in differences = -1.5 days; P < .001). However, BPCI participants did not change their PAC referral patterns to reduce dispersion or refer patients to higher-quality PAC providers. Hospitals that were more successful in reducing Medicare payments started with higher payments and higher use of institutional PAC settings and demonstrated greater drops in use and duration of institutional PAC, but no differences in dispersion or referral to high-quality providers. Reductions in spending under BPCI were driven by a shift from higher- to lower-cost discharge settings, and by shortening the duration of institutional PAC. Hospitals that reduced payments the most had the highest spending at baseline. J Am Geriatr Soc 67:1027-1035, 2019.

Joynt Maddox KE ，Orav EJ ，Zheng J ，Epstein AM ... -  《-》

How Do Frail Medicare Beneficiaries Fare Under Bundled Payments?

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

Joynt Maddox KE ，Orav EJ ，Zheng J ，Epstein AM ... -  《-》

Cost of Joint Replacement Using Bundled Payment Models.

Navathe AS ，Troxel AB ，Liao JM ，Nan N ，Zhu J ，Zhong W ，Emanuel EJ ... -  《-》

Bundled Payments for Care Improvement: Health System Experience With Lower Extremity Joint Replacement at Higher and Lower Volume Hospitals.

The Bundled Payments for Care Improvement (BPCI) initiative was introduced in 2013 to reduce Medicare healthcare costs while preserving or enhancing quality. We examined data from a metropolitan healthcare system comprised of 1 higher volume hospital and 4 lower volume hospitals that voluntarily elected to participate in the BPCI Major Joint Replacement of the Lower Extremity Model 2, beginning July 1, 2015. Stratifying the data by hospital volume, we determined how costs changed during the 16-month period when all 5 hospitals participated compared to the 1-year period preceding BPCI participation, where savings were achieved, and how the hospitals were rewarded. The Medicare data included the 90-day target for each episode and actual part A and part B spending for the anchor hospitalization plus all post-acute payments including inpatient rehabilitation, skilled nursing, home health, outpatient physical therapy, and hospital readmissions. The mean episode of care cost decreased by 11.1% (from $21,324 to $18,953) at the higher volume hospitals and by 8.3% (from $25,724 to $23,584) at the lower volume hospitals during BPCI participation compared to the preceding year. The savings were achieved by reducing the use of inpatient rehabilitation, shortening the length of stay at skilled nursing facilities, and decreasing readmission rates. Although the higher volume hospital achieved an increased mean savings of $230 per episode compared to the lower volume hospitals ($2371 vs $2141), it was penalized $490 per episode after reconciling the actual Medicare expenditures with the BPCI targets while the lower volume hospitals received a mean reward of $315 per episode. The BPCI initiative decreased costs and readmissions within our healthcare system. Despite substantial savings compared to the preceding year, the higher volume hospital's low target derived from its 2009-2012 baseline costs was not achieved which resulted in a penalty and led it to withdraw from the BPCI initiative in October 2016.

McAsey CJ ，Johnson EM ，Hopper RH Jr ，Engh CA Jr ... -  《-》

Association Between Hospital Participation in a Medicare Bundled Payment Initiative and Payments and Quality Outcomes for Lower Extremity Joint Replacement Episodes.

Dummit LA ，Kahvecioglu D ，Marrufo G ，Rajkumar R ，Marshall J ，Tan E ，Press MJ ，Flood S ，Muldoon LD ，Gu Q ，Hassol A ，Bott DM ，Bassano A ，Conway PH ... -  《-》