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

ABSTRACT: 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.

SUBMITTER: Zhu JM

PROVIDER: S-EPMC6788623 | biostudies-literature | 2019 Jul

REPOSITORIES: biostudies-literature

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

Zhu Jane M JM Navathe Amol A Yuan Yihao Y Dykstra Sarah S Werner Rachel M RM

The American journal of managed care 20190701 7

<h4>Objectives</h4>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.<h4>Study design</h4>Retrospective observational study using difference-in-differences analysis.<h4>Methods</h4>We used Medicare claims data from 2010 to 2015 to identify admissions for lower joint replacement s ...[more]

PMID: 31318505

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Project description:ImportanceMedicare 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.ObjectiveTo 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 participantsObservational 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.ExposuresAdmission to a BPCI model 3-participating SNF.Main outcomes and measuresThe 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.ResultsThere 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 relevanceAmong 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.

Project description:Policy Points Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee-for-service contracting, although bundled payment models may not reduce absolute costs. Bundled payments may be more effective than fee-for-service payments in containing costs for certain medical conditions. For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions. Bundled payment contracting involves trade-offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee-for-service payment.ContextBundled payments have been promoted as an alternative to fee-for-service payments that can mitigate the incentives for service volume under the fee-for-service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality.MethodsWe examined the history and features of 16 of Medicare's bundled payment programs involving hospital-initiated episodes of care and conducted a literature review of articles about those programs. Database and additional searches yielded 1,479 articles. We evaluate the studies' methodological quality and summarize the quantitative findings about Medicare expenditures and quality of care from 37 studies that used higher-quality research designs.FindingsMedicare's bundled payment initiatives have varied in their design features, such as episode scope and duration. Many initiatives were associated with little to no reduction in Medicare expenditures, unless large pricing discounts for providers were negotiated in advance. Initiatives that included post-acute care services were associated with lower expenditures for certain conditions. Hospitals may have been able to reduce internal production costs with help from physicians via gainsharing. Most initiatives were not associated with significant changes in quality of care, as measured by readmission and mortality rates. Of the significant changes in readmission rates, the results were mixed, showing increases and decreases associated with bundled payments. Some evidence suggested that worse patient outcomes were associated bundled payments, although most results were not statistically significant. Results on case-mix selection were mixed: Several initiatives were associated with reductions in episode severity, whereas others were associated with little change.ConclusionsBundled payments for hospital-initiated episodes may be a good alternative to fee-for-service payments. Bundled payments can help slow the growth of payer spending, although they do not necessarily reduce absolute spending. They are associated with lower provider production costs, and there is no overwhelming evidence of compromised quality. However, designing a bundled payment contract that is attractive to both providers and payers proves to be a challenge.

Project description:Background/objectivesApproximately half of individuals newly admitted to long-term care (LTC) nursing homes (NHs) experienced a prior hospitalization followed by discharge to a skilled nursing facility (SNF). The objective was to examine characteristics associated with new institutionalizations of older adults on this care trajectory.DesignRetrospective cohort study.SettingSNFs and LTC NHs.PatientsMedicare fee-for-service beneficiaries admitted to 7,442 SNFs in 2013 (N = 597,986).MeasurementsWe used demographic and clinical characteristics from Medicare data and the Minimum Data Set. We defined "new institutionalization" as LTC NH residence for longer than 90 non-SNF days, starting within 6 months of hospital discharge.ResultsFor individuals who survived 6 months after hospital discharge, the overall rate of new LTC institutionalizations was 10.0% (N = 59,736). Older age, white race, being unmarried, Medicaid eligibility, higher income, more comorbidities, cognitive impairment, depression, functional limitations, hallucinations and delusions, aggressive behavior, incontinence, and pressure ulcers were associated with higher adjusted odds of new LTC institutionalization. In analyses stratified according to race and ethnicity, higher income was associated with lower odds of LTC institutionalization for whites (odds ratio (OR) = 0.92, 95% confidence interval (CI) = 0.89-0.96) and greater odds for blacks (OR = 1.40, 95% CI = 1.27-1.55) and Hispanics (OR = 1.44, 95% CI = 1.25-1.66). Moderate or severe depression, functional limitations, hallucinations and delusions, aggressive behavior, and being unmarried were stronger risk factors for LTC for cognitively intact individuals than for those with moderate to severe cognitive impairment. Being unmarried and having more comorbidities were stronger predictors in those aged 66 to 70 than in those aged 81 to 85 and 91 and older.ConclusionAssociations between risk factors and new LTC institutionalizations varied according to race and ethnicity, age, and level of cognitive function. Programs that target older adults at greater risk may be an effective strategy for reducing new institutionalizations and fostering aging in place.

Project description:STUDY DESIGN:Retrospective analysis of Medicare claims linked to hospital participation in the Center for Medicare and Medicaid Innovation's episode-based Bundled Payment for Care Improvement (BPCI) program for lumbar fusion. OBJECTIVE:To describe the early effects of BPCI participation for lumbar fusion on 90-day reimbursement, procedure volume, reoperation, and readmission. SUMMARY OF BACKGROUND DATA:Initiated on January 1, 2013, BPCI's voluntary bundle payment program provides a predetermined payment for services related to a Diagnosis-Related Group-defined "triggering event" over a defined time period. As an alternative to fee-for-service, these reforms shift the financial risk of care on to hospitals. METHODS:We identified fee-for-service beneficiaries over age 65 undergoing a lumbar fusion in 2012 or 2013, corresponding to the years before and after BPCI initiation. Hospitals were grouped based on program participation status as nonparticipants, preparatory, or risk-bearing. Generalized estimating equation models adjusting for patient age, sex, race, comorbidity, and hospital size were used to compare changes in episode costs, procedure volume, and safety indicators based on hospital BPCI participation. RESULTS:We included 89,605 beneficiaries undergoing lumbar fusion, including 36% seen by a preparatory hospital and 7% from a risk-bearing hospital. The mean age of the cohort was 73.4 years, with 59% women, 92% White, and 22% with a Charlson Comorbidity Index of 2 or more. Participant hospitals had greater procedure volume, bed size, and total discharges. Relative to nonparticipants, risk-bearing hospitals had a slightly increased fusion procedure volume from 2012 to 2013 (3.4% increase vs. 1.6% decrease, P?=?0.119), did not reduce 90-day episode of care costs (0.4% decrease vs. 2.9% decrease, P?=?0.044), increased 90-day readmission rate (+2.7% vs. -10.7%, P?=?0.043), and increased repeat surgery rates (+30.6% vs. +7.1% points, P?=?0.043). CONCLUSION:These early, unintended trends suggest an imperative for continued monitoring of BPCI in lumbar fusion. LEVEL OF EVIDENCE:3.

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

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

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