Changes in Cardiovascular Spending, Care Utilization, and Clinical Outcomes Associated With Participation in Bundled
Sukruth A Shashikumar1,2, Jie Zheng3, E John Orav4,5
1Department of Medicine (S.A.S.), Brigham and Women's Hospital, Boston, MA.
Insights
The Bundled Payments for Care Improvement - Advanced (BPCI-A) initiative did not reduce spending or improve quality for cardiovascular conditions. This Medicare program showed no significant changes in spending, utilization, readmissions, or mortality for cardiac episodes.
Area of Science:
- Health economics and policy
- Cardiovascular medicine
- Healthcare quality improvement
Background:
- The Bundled Payments for Care Improvement - Advanced (BPCI-A) initiative is a Medicare program designed to lower healthcare spending for specific episodes of care.
- Cardiovascular diseases are a major contributor to Medicare expenditures, making them a key focus area for BPCI-A.
- The impact of BPCI-A on spending and quality for cardiovascular conditions remains under investigation.
Purpose of the Study:
- To evaluate whether the BPCI-A initiative is associated with reductions in healthcare spending for cardiovascular conditions.
- To assess the effect of BPCI-A on quality of care, including patient complexity, utilization, readmissions, and mortality for cardiac episodes.
- To compare outcomes between hospitals participating in BPCI-A and matched non-participating control hospitals.
Main Methods:
- A retrospective cohort study design was employed using Medicare claims data.
- Difference-in-differences analyses were conducted for patients discharged between January 1, 2017, and September 30, 2019.
- Primary outcomes included differential changes in spending for cardiac medical and procedural episodes; secondary outcomes assessed patient complexity, care utilization, healthy days at home, readmissions, and mortality.
Main Results:
- No significant differential changes in spending were observed for cardiac medical episodes (+$16) or procedural episodes (+$171) at BPCI-A hospitals compared to controls.
- Minimal differential changes were found in physician care patterns, patient complexity, or care utilization.
- There were no statistically significant differences in 90-day readmission rates or mortality between BPCI-A and control hospitals for either medical or procedural cardiac episodes.
Conclusions:
- Participation in the BPCI-A program was not associated with reductions in healthcare spending for the targeted cardiovascular conditions.
- The initiative did not lead to significant improvements in quality of care, as measured by utilization, readmissions, or mortality.
- BPCI-A did not demonstrate effectiveness in achieving its goals for cardiovascular medical events or procedures within the study period.
Background:
Bundled Payments for Care Improvement - Advanced (BPCI-A) is a Medicare initiative that aims to incentivize reductions in spending for episodes of care that start with a hospitalization and end 90 days after discharge. Cardiovascular disease, an important driver of Medicare spending, is one of the areas of focus BPCI-A. It is unknown whether BPCI-A is associated with spending reductions or quality improvements for the 3 cardiovascular medical events or 5 cardiovascular procedures in the model.
Methods:
In this retrospective cohort study, we conducted difference-in-differences analyses using Medicare claims for patients discharged between January 1, 2017, and September 30, 2019, to assess differences between BPCI-A hospitals and matched nonparticipating control hospitals. Our primary outcomes were the differential changes in spending, before versus after implementation of BPCI-A, for cardiac medical and procedural conditions at BPCI-A hospitals compared with controls. Secondary outcomes included changes in patient complexity, care utilization, healthy days at home, readmissions, and mortality.
Results:
Baseline spending for cardiac medical episodes at BPCI-A hospitals was $25 606. The differential change in spending for cardiac medical episodes at BPCI-A versus control hospitals was $16 (95% CI, -$228 to $261; P=0.90). Baseline spending for cardiac procedural episodes at BPCI-A hospitals was $37 961. The differential change in spending for cardiac procedural episodes was $171 (95% CI, -$429 to $772; P=0.58). There were minimal differential changes in physicians' care patterns such as the complexity of treated patients or in their care utilization. At BPCI-A versus control hospitals, there were no significant differential changes in rates of 90-day readmissions (differential change, 0.27% [95% CI, -0.25% to 0.80%] for medical episodes; differential change, 0.31% [95% CI, -0.98% to 1.60%] for procedural episodes) or mortality (differential change, -0.14% [95% CI, -0.50% to 0.23%] for medical episodes; differential change, -0.36% [95% CI, -1.25% to 0.54%] for procedural episodes).
Conclusions:
Participation in BPCI-A was not associated with spending reductions, changes in care utilization, or quality improvements for the cardiovascular medical events or procedures offered in the model.
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