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Original Investigation
Innovations in Health Care Delivery
September 27, 2016

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

Author Affiliations
  • 1The Lewin Group, Falls Church, Virginia
  • 2Centers for Medicare & Medicaid Services, Baltimore, Maryland
  • 3CareFirst Blue Cross Blue Shield, Baltimore, Maryland
  • 4Abt Associates Inc, Cambridge, Massachusetts
JAMA. 2016;316(12):1267-1278. doi:10.1001/jama.2016.12717
Abstract

Importance  Bundled Payments for Care Improvement (BPCI) is a voluntary initiative of the Centers for Medicare & Medicaid Services to test the effect of holding an entity accountable for all services provided during an episode of care on episode payments and quality of care.

Objective  To evaluate whether BPCI was associated with a greater reduction in Medicare payments without loss of quality of care for lower extremity joint (primarily hip and knee) replacement episodes initiated in BPCI-participating hospitals that are accountable for total episode payments (for the hospitalization and Medicare-covered services during the 90 days after discharge).

Design, Setting, and Participants  A difference-in-differences approach estimated the differential change in outcomes for Medicare fee-for-service beneficiaries who had a lower extremity joint replacement at a BPCI-participating hospital between the baseline (October 2011 through September 2012) and intervention (October 2013 through June 2015) periods and beneficiaries with the same surgical procedure at matched comparison hospitals.

Exposure  Lower extremity joint replacement at a BPCI-participating hospital.

Main Outcomes and Measures  Standardized Medicare-allowed payments (Medicare payments), utilization, and quality (unplanned readmissions, emergency department visits, and mortality) during hospitalization and the 90-day postdischarge period.

Results  There were 29 441 lower extremity joint replacement episodes in the baseline period and 31 700 in the intervention period (mean [SD] age, 74.1 [8.89] years; 65.2% women) at 176 BPCI-participating hospitals, compared with 29 440 episodes in the baseline period (768 hospitals) and 31 696 episodes in the intervention period (841 hospitals) (mean [SD] age, 74.1 [8.92] years; 64.9% women) at matched comparison hospitals. The BPCI mean Medicare episode payments were $30 551 (95% CI, $30 201 to $30 901) in the baseline period and declined by $3286 to $27 265 (95% CI, $26 838 to $27 692) in the intervention period. The comparison mean Medicare episode payments were $30 057 (95% CI, $29 765 to $30 350) in the baseline period and declined by $2119 to $27 938 (95% CI, $27 639 to $28 237). The mean Medicare episode payments declined by an estimated $1166 more (95% CI, −$1634 to −$699; P < .001) for BPCI episodes than for comparison episodes, primarily due to reduced use of institutional postacute care. There were no statistical differences in the claims-based quality measures, which included 30-day unplanned readmissions (−0.1%; 95% CI, −0.6% to 0.4%), 90-day unplanned readmissions (−0.4%; 95% CI, −1.1% to 0.3%), 30-day emergency department visits (−0.1%; 95% CI, −0.7% to 0.5%), 90-day emergency department visits (0.2%; 95% CI, −0.6% to 1.0%), 30-day postdischarge mortality (−0.1%; 95% CI, −0.3% to 0.2%), and 90-day postdischarge mortality (−0.0%; 95% CI, −0.3% to 0.3%).

Conclusions and Relevance  In the first 21 months of the BPCI initiative, Medicare payments declined more for lower extremity joint replacement episodes provided in BPCI-participating hospitals than for those provided in comparison hospitals, without a significant change in quality outcomes. Further studies are needed to assess longer-term follow-up as well as patterns for other types of clinical care.

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