From Winners to Losers: The Methodology of Bundled Payments for Care Improvement Advanced Disincentivizes Participation in Bundled Payment Programs

2020 ◽  
Author(s):  
Chad A. Krueger ◽  
Michael Yayac ◽  
Chris Vannello ◽  
John Wilsman ◽  
Matthew S. Austin ◽  
...  
Keyword(s):  
Bundled Payment ◽  
Bundled Payments ◽  
Care Improvement

Medicare bundles for arthroplasty

2021 ◽  
Vol 103-B (6 Supple A) ◽  
pp. 119-125
Author(s):  
Bryan D. Springer ◽  
Jordan McInerney
Keyword(s):  
Acute Care ◽  
Acute Care Hospitals ◽  
Drop Out ◽  
Retention Rates ◽  
Fee For Service ◽  
Target Price ◽  
High Performing ◽  
Bundled Payment ◽  
Bundled Payments ◽  
Care Improvement

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.

2020 John N. Insall Award: Removal of total knee arthroplasty from the inpatient-only list adversely affects bundled payment programmes

2020 ◽  
Vol 102-B (6_Supple_A) ◽  
pp. 19-23 ◽  
Author(s):  
Michael Yayac ◽  
Nicholas Schiller ◽  
Matthew S. Austin ◽  
P. Maxwell Courtney
Keyword(s):  
Total Knee Arthroplasty ◽  
Knee Arthroplasty ◽  
Hospital Inpatient ◽  
Target Price ◽  
Bundled Payment ◽  
Bundled Payments ◽  
Medicare Patients ◽  
Total Knee ◽  
Care Improvement ◽  
The Impact

Aims The purpose of this study was to determine the impact of the removal of total knee arthroplasty (TKA) from the Medicare Inpatient Only (IPO) list on our Bundled Payments for Care Improvement (BPCI) Initiative in 2018. Methods We examined our institutional database to identify all Medicare patients who underwent primary TKA from 2017 to 2018. Hospital inpatient or outpatient status was cross-referenced with Centers for Medicare & Medicaid Services (CMS) claims data. Demographics, comorbidities, and outcomes were compared between patients classified as ‘outpatient’ and ‘inpatient’ TKA. Episode-of-care BPCI costs were then compared from 2017 to 2018. Results Of the 2,135 primary TKA patients in 2018, 908 (43%) were classified as an outpatient and were excluded from BPCI. Inpatient classified patients had longer mean length of stay (1.9 (SD 1.4) vs 1.4 (SD 1.7) days, p < 0.001) and higher rates of discharge to rehabilitation (17% vs 3%, p < 0.001). Post-acute care costs increased when comparing the BPCI patients from 2017 to 2018, ($5,037 (SD $7,792) vs $5793 (SD $8,311), p = 0.010). The removal of TKA from the IPO list turned a net savings of $53,805 in 2017 into a loss of $219,747 in 2018 for our BPCI programme. Conclusions Following the removal of TKA from the IPO list, nearly half of the patients at our institution were inappropriately classified as an outpatient. Our target price was increased and our institution realized a substantial loss in 2018 BPCI despite strong quality metrics. CMS should address its negative implications on bundled payment programmes. Cite this article: Bone Joint J 2020;102-B(6 Supple A):19–23.

scholarly journals Overlap between Medicare’s Voluntary Bundled Payment and Accountable Care Organization Programs

2019 ◽  
Vol 15 (6) ◽  
pp. 356-358 ◽  
Author(s):  
Amol S Navathe ◽  
Claire Dinh ◽  
Sarah E Dykstra ◽  
Rachel M Werner ◽  
Joshua M Liao
Keyword(s):  
Policy Implications ◽  
Care Organization ◽  
Accountable Care ◽  
Bundled Payment ◽  
Bundled Payments ◽  
Medicare Data ◽  
Shared Savings ◽  
Care Improvement ◽  
Medicare Shared Savings Program ◽  
A Share

Accountable care organizations (ACOs) and bundled payments represent prominent value-based payment models, but the magnitude of overlap between the two models has not yet been described. Using Medicare data, we defined overlap based on attribution to Medicare Shared Savings Program (MSSP) ACOs and hospitalization for Bundled Payments for Care Improvement (BPCI) episodes at BPCI participant hospitals. Between 2013 and 2016, overlap as a share of ACO patients increased from 2.7% to 10% across BPCI episodes, while overlap as a share of all bundled payment patients increased from 19% to 27%. Overlap from the perspectives of both ACO and bundled payments varied by specific episode. In the first description of overlap between ACOs and bundled payments, one in every ten MSSP patients received care under BPCI by the end of our study period, whereas more than one in every four patients receiving care under BPCI were also attributed to MSSP. Policymakers should consider strategies to address the clinical and policy implications of increasing payment model overlap.

scholarly journals Race, Bundled Payment Policy, and Discharge Destination After TKA: The Experience of an Urban Academic Hospital

2018 ◽  
Vol 9 ◽  
pp. 215145931880322 ◽  
Author(s):  
Michele Fang ◽  
Eric Hume ◽  
Said Ibrahim
Keyword(s):  
African American ◽  
Elective Surgery ◽  
Skilled Nursing Facility ◽  
Inpatient Rehabilitation ◽  
Adverse Outcomes ◽  
Discharge Destination ◽  
Bundled Payment ◽  
Bundled Payments ◽  
Care Improvement ◽  
White Patients

Background: Total knee arthroplasty (TKA) provides good clinical outcomes for the treatment of end-stage osteoarthritis; however, discharge destination after TKA has major implications on postoperative adverse outcomes and readmissions. With the initiation of Bundled Payments for Care Improvement (BPCI), it is unclear how racial disparities in discharge destination after TKA will be affected by the new bundled payment for TKA. Methods: Bundled Payments for Care Improvement was implemented in July 01, 2014, at the University of Pennsylvania. We compared differences during early implementation (July 1, 2014, to, March 30, 2016) and during late policy implementation (April 1, 2016, to February 28, 2017) in patient characteristics (including race: African American [AA], white, and other race), discharge destination (skilled nursing facility [SNF], inpatient rehabilitation facility, home, home with home health, or other), and outcomes. Results: We identified 2276 patients who underwent TKA (43.8% AA, 48.2% white, and 8.0% other race). African American patients were more likely to be discharged to SNF as opposed to home than white patients both during the early BPCI (AA: 53.0%, n = 320; white: 32.4%, n = 210, P < .05) and late BPCI implementation (AA: 44.4%, n = 169, white: 26.9%, n = 120, P < .05), though all races showed trends to decreasing SNF use during the late BPCI implementation. Discussion: There were no significant differences in readmissions, length of stay, mortality, or intensive care unit days during early and late implementation of BPCI or when AA patients were compared to white patients. Conclusion: We found no significant changes in racial variations in discharge destination and outcomes after elective TKA. Bundled Payments for Care Improvement has encouraged better preoperative preparation of patients and discharge planning; however, payment reforms alone might not be sufficient to address variation in post-op management following elective surgery.

‘Bundle busters’

2019 ◽  
Vol 101-B (7_Supple_C) ◽  
pp. 64-69 ◽  
Author(s):  
A. J. Wodowski ◽  
C. E. Pelt ◽  
J. A. Erickson ◽  
M. B. Anderson ◽  
J. M. Gililland ◽  
...  
Keyword(s):  
Risk Factors ◽  
Patient Specific ◽  
Bundled Payment ◽  
Bundled Payments ◽  
Preoperative Risk Factors ◽  
Physical Status Classification ◽  
Increased Risk ◽  
Comorbidity Index ◽  
American Society ◽  
Care Improvement

Aims The Bundled Payments for Care Improvement (BPCI) initiative has identified pathways for improving the value of care. However, patient-specific modifiable and non-modifiable risk factors may increase costs beyond the target payment. We sought to identify risk factors for exceeding our institution’s target payment, the so-called ‘bundle busters’. Patients and Methods Using our data warehouse and Centers for Medicare and Medicaid Services (CMS) data we identified all 412 patients who underwent total joint arthroplasty and qualified for our institution’s BPCI model, between July 2015 and May 2017. Episodes where CMS payments exceeded the target payment were considered ‘busters’ (n = 123). Risk ratios (RRs) were calculated using a modified Poisson regression analysis. Results An increased risk of exceeding the target payment was significantly associated with increasing age (adjusted RR 1.04, 95% confidence interval (CI) 1.01 to 1.06) and body mass index (adjusted RR 1.03, 95% CI 1.003 to 1.06). Eight comorbid risk factors were also identified (all p < 0.05), only two of which were considered to be potentially modifiable (diabetes with complications and preoperative anaemia). An American Society of Anesthesiologist physical status classification system (ASA) score ≥ 3 (adjusted RR 2.3, 95% CI 1.67 to 3.18) and Charlson Comorbidity Index (CCI) ≥ 3 (adjusted RR 1.94, 95% CI 1.45 to 2.60) were risk factors for bundle busting. Conclusion Non-modifiable preoperative risk factors can increase costs and exceed the target payment. Future bundled payment models should incorporate the stratification of risk. Cite this article: Bone Joint J 2019;101-B(7 Supple C):64–69

scholarly journals Simulating Costs for Episode-Based Bundled Payments for Cranial Neurosurgical Procedures

Neurosurgery ◽  
2019 ◽  
Vol 66 (Supplement_1) ◽  
Author(s):  
Zachary A Medress ◽  
Beatrice Ugiliweneza ◽  
Jonathon J Parker ◽  
Dengzhi Wang ◽  
Eric Burton ◽  
...  
Keyword(s):  
Malignant Glioma ◽  
Administrative Database ◽  
Orthopedic Procedures ◽  
Neurosurgical Procedures ◽  
Bundled Payment ◽  
Bundled Payments ◽  
Significant Variability ◽  
Cost Variability ◽  
Care Improvement ◽  
The Cost

Abstract INTRODUCTION Episode-based bundled payments were introduced by Medicare in 2013 as the Bundled Care Improvement Initiative (BPCI) in order to improve care coordination and cost efficiency. BPCI has been implemented for orthopedic, cardiac, and spine procedures, but has not yet been applied to cranial neurosurgical procedures. We project the cost of episode-based bundled payments for cranial neurosurgical procedures. METHODS We performed a large retrospective observational study using the MarketScan administrative database to project bundled payment costs for common cranial neurosurgical procedures. Operations were classified into 4 groups: craniotomy for unruptured aneurysm, craniotomy for meningioma, craniotomy for malignant glioma, and craniotomy for metastasis. We project 30-, 60-, and 90-d bundle payments for each category, and analyze the contributions of postdischarge costs to total bundle payments at each time point. RESULTS We identified 15 276 procedures that met our inclusion criteria. We observed significant variability between groups, with 90-d bundle projected costs ranging from $58,200 for craniotomy for meningioma to $102,073 for craniotomy for malignant glioma. We also found significant variability in projected bundled payments within each class of operation. On average, payment for the index hospitalization accounted for 85% of projected costs for a 30-d bundle and 70.5% of projected costs for a 90-d bundle. Multivariate analysis showed that medical comorbidities, adjuvant therapies, and payer status significantly contributed to projected cranial bundle costs. CONCLUSION For the first time in our knowledge, we report projected costs of 30-, 60-, and 90-d episode-based bundled payments for common elective vascular and tumor cranial operations. As previously identified in the orthopedic literature, there is significant cost variability in total bundle payments within each cranial procedure. Compared to spine and orthopedic procedures, postdischarge costs significantly impact total bundle payments in cranial neurosurgery.

Simulating Episode-Based Bundled Payments for Cranial Neurosurgical Procedures

Neurosurgery ◽  
2019 ◽  
Vol 87 (1) ◽  
pp. 86-95 ◽  
Author(s):  
Zachary Medress ◽  
Beatrice Ugiliweneza ◽  
Jonathon Parker ◽  
Dengzhi Wang ◽  
Eric Burton ◽  
...  
Keyword(s):  
Multivariable Analysis ◽  
Administrative Database ◽  
Orthopedic Procedures ◽  
Neurosurgical Procedures ◽  
Bundled Payment ◽  
Bundled Payments ◽  
Significant Variability ◽  
Care Facilities ◽  
Care Improvement ◽  
First Time

Abstract BACKGROUND Episode-based bundled payments were introduced by Medicare in 2013 as the Bundled Payments for Care Improvement (BPCI) in order to improve care coordination and cost efficiency. BPCI has not yet been applied to cranial neurosurgical procedures. OBJECTIVE To determine projected values of episode-based bundled payments when applied to common cranial neurosurgical procedures using retrospective data from a large database. METHODS We performed a large retrospective observational study using the MarketScan administrative database to project bundled payment payments for 4 groups of common cranial neurosurgical procedures. RESULTS We identified 15 276 procedures that met our inclusion criteria. We observed significant variability between groups, with 90-d bundle projected payments ranging from $ 58,200 for craniotomy for meningioma to $ 102,073 for craniotomy for malignant glioma. We also found significant variability in projected bundled payments within each class of operation. On average, payment for the index hospitalization accounted for 85% of projected payments for a 30-d bundle and 70.5% of projected payments for a 90-d bundle. Multivariable analysis showed that hospital readmission, discharge to postacute care facilities, venous-thrombo-embolism, medical comorbidities, adjuvant therapies, and payer status significantly contributed to projected cranial bundle payments. CONCLUSION For the first time, to our knowledge, we project the values of episode-based bundled payments for common vascular and tumor cranial operations. As previously identified in orthopedic procedures, there is significant variability in total bundle payments within each cranial procedure. Compared to spine and orthopedic procedures, postdischarge care significantly impacts total bundle payments in cranial neurosurgery.

Abstract T P248: All Wrapped Up in a Bundle: Aultman Hospital’s Journey with the Bundled Payment for Care Improvements in Stroke

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Angela M McGee ◽  
Jennifer M Brackman
Keyword(s):  
Steering Committee ◽  
Transitions Of Care ◽  
Stroke Patients ◽  
Bundled Payment ◽  
Bundled Payments ◽  
Strong Focus ◽  
Stroke Team ◽  
Nurse Navigator ◽  
Care Improvement ◽  
The Continuum

Background: In January of 2013, Aultman Hospital was selected among 500 hospitals nationwide to participate in the CMS Bundled Payments for Care Improvement (BPCI) Initiative. The hospital chose to participate with this initiative using the stroke patient population during the acute hospital stay and services up to 90 days after hospital discharge. During the discovery phase, data was analyzed that helped to identify opportunities within the transitions of care across the continuum for stroke patients. Purpose: To identify areas of opportunity to improve transitions of care across the continuum for stroke patients under the bundled payment initiative. Methods: A multi-disciplinary steering committee, driven by engaged physician champions, came together to review the analyzed data and identify care coordination opportunities. Reviewed data included stroke patients from 2008 to current, with a strong focus on readmissions and complications of care. Data analysis was performed internally by the steering committee and externally by Brandeis University. Results: The committee was able to identify trends in readmissions, potential quality and financial opportunities, create a stroke opportunity matrix and stroke bundled payment dashboard, and enhance the partnership between Aultman Hospital and Aultman Post-Acute Care by creating a Continuum of Care Collaboration Plan for stroke patients. A potential nurse navigator was also identified as a possible need. The position would provide a consistent person(s) that would ensure that individual needs are met across the continuum and possibly prevent readmissions. The team was also able to provide feedback to CMS regarding the BPCI, which ultimately were consistent with the changes CMS made to proposed data collection and reporting requirements. Conclusions: Throughout Aultman’s journey with the BPCI, common themes remained: the need for collaboration of services for stroke patients to ensure continuity of care and to streamline the encounter for the patient. Aultman’s BPCI for Stroke team was able to identify ways to reduce readmissions, prevent complications of care, explore the potential for a stroke nurse navigator, and reduce the overall financial impact to an overburdened public health system.

An Early Look at the Effects of the Medicare Bundled Payments for Care Improvement: Evidence from Presence Health

2018 ◽  
Author(s):  
Nathan Petek ◽  
Will Clark ◽  
Jonas de Souza ◽  
Heidi Graham ◽  
Svati Patel ◽  
...  
Keyword(s):  
Bundled Payments ◽  
Care Improvement
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