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 Impact on Oncology Practices of Including Drug Costs in Bundled Payments

2018 ◽  
Vol 14 (5) ◽  
pp. e259-e268 ◽  
Author(s):  
Jeffery C. Ward ◽  
Laura A. Levit ◽  
Ray D. Page ◽  
John E. Hennessy ◽  
John V. Cox ◽  
...  
Keyword(s):  
Complex Disease ◽  
Drug Costs ◽  
Fee For Service ◽  
Patient Case ◽  
Bundled Payment ◽  
Bundled Payments ◽  
Average Patient ◽  
Cancer Types ◽  
The Impact ◽  
Probabilistic Risk

Introduction: This analysis evaluates the impact of bundling drug costs into a hypothetic bundled payment. Methods: An economic model was created for patient vignettes from: advanced-stage III colon cancer and metastatic non–small-cell lung cancer. First quarter 2016 Medicare reimbursement rates were used to calculate the average fee-for-service (FFS) reimbursement for these vignettes. The probabilistic risk faced by practices was captured by the type of patients seen in practices and randomly assigned in a Monte Carlo simulation on the basis of the given distribution of patient types within each cancer. Simulations were replicated 1,000 times. The impact of bundled payments that include drug costs for various practice sizes and cancer types was quantified as the probability of incurring a loss at four magnitudes: any loss, > 10%, > 20%, or > 30%. A loss was defined as receiving revenue from the bundle that was less than what the practice would have received under FFS; the probability of loss was calculated on the basis of the number of times a practice reported a loss among the 1,000 simulations. Results: Practices that treat a substantial proportion of patients with complex disease compared with the average patient in the bundle would have revenue well below that expected from FFS. Practices that treat a disproportionate share of patients with less complex disease, as compared with the average patient in the bundle, would have revenue well above the revenue under FFS. Overall, bundled payments put practices at greater risk than FFS because their patient case mix could greatly skew financial performance. Conclusion: Including drug costs in a bundle is subject to the uncontrollable probabilistic risk of patient case mixes.

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.

Target Price Adjustment for Hip Fractures Is Not Sufficient in the Bundled Payments for Care Improvement Initiative

2021 ◽  
Vol 36 (1) ◽  
pp. 47-53 ◽  
Author(s):  
Hope Skibicki ◽  
Michael Yayac ◽  
Chad A. Krueger ◽  
P. Maxwell Courtney
Keyword(s):  
Hip Fractures ◽  
Price Adjustment ◽  
Target Price ◽  
Bundled Payments ◽  
Care Improvement

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.

scholarly journals How Do the Hospital Prices Paid by Medicare Advantage Plans and Commercial Plans Compare With Medicare Fee-for-Service Prices?

2018 ◽  
Vol 55 ◽  
pp. 004695801877965
Author(s):  
Jared Lane K. Maeda ◽  
Lyle Nelson
Keyword(s):  
Health Care ◽  
Acute Care ◽  
Health Care Cost ◽  
Acute Care Hospitals ◽  
Fee For Service ◽  
Medicare Advantage ◽  
Medicare Beneficiaries ◽  
Metropolitan Statistical Areas

The prices that private insurers pay hospitals have received considerable attention in recent years, but most of that literature has focused on the commercially insured population. Although nearly one-third of Medicare beneficiaries are enrolled in a Medicare Advantage (MA) plan, little is known about the prices paid to hospitals by the private insurers that administer such plans. More information on the hospital prices paid by MA plans would provide additional insights into whether MA prices are more closely tied to Medicare fee-for-service (FFS) prices or commercial prices. Moreover, information on whether the hospital prices paid by MA plans vary with market characteristics or other factors would be useful for evaluating the performance of the MA program and analyzing proposals to modify it. In this study, we compared the hospital prices paid by MA plans and commercial plans with Medicare FFS prices using 2013 claims from the Health Care Cost Institute (HCCI) database. The HCCI claims were used to calculate hospital prices for private insurers, and Medicare’s payment rules were used to estimate Medicare FFS prices. We focused on stays at acute care hospitals in metropolitan statistical areas (MSAs). We found MA prices to be roughly equal to Medicare FFS prices, on average, but commercial prices were 89% higher than FFS prices. In addition, commercial prices varied greatly across and within MSAs, but MA prices varied much less.

‘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

Republished: Big Things Come in Bundled Packages: Implications of Bundled Payment Systems in Health Care Reimbursement Reform

2019 ◽  
Vol 34 (5) ◽  
pp. 482-487 ◽  
Author(s):  
Dennis R. Delisle
Keyword(s):  
Health Care ◽  
Quality Care ◽  
Clinical Settings ◽  
Fee For Service ◽  
Payment Systems ◽  
High Quality ◽  
Bundled Payment ◽  
High Quality Care ◽  
Bundled Payments ◽  
Daunting Task

With passage of the Affordable Care Act, the ever-evolving landscape of health care braces for another shift in the reimbursement paradigm. As health care costs continue to rise, providers are pressed to deliver efficient, high-quality care at flat to minimally increasing rates. Inherent systemwide inefficiencies between payers and providers at various clinical settings pose a daunting task for enhancing collaboration and care coordination. A change from Medicare’s fee-for-service reimbursement model to bundled payments offers one avenue for resolution. Pilots using such payment models have realized varying degrees of success, leading to the development and upcoming implementation of a bundled payment initiative led by the Center for Medicare and Medicaid Innovation. Delivery integration is critical to ensure high-quality care at affordable costs across the system. Providers and payers able to adapt to the newly proposed models of payment will benefit from achieving cost reductions and improved patient outcomes and realize a competitive advantage.

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