Patients are grouped by surgical procedure. Q indicates quarter.
Jubelt LE, Goldfeld KS, Chung W, Blecker SB, Horwitz LI. Changes in Discharge Location and Readmission Rates Under Medicare Bundled Payment. JAMA Intern Med. 2016;176(1):115-117. doi:10.1001/jamainternmed.2015.6265
Patients are often referred for postacute care after hospitalization to improve outcomes and reduce readmissions. The use of postacute care has grown rapidly, with costs doubling since 2001.1,2 Although such care can take place at home, skilled nursing facilities, or inpatient rehabilitation facilities, facility-based care is more expensive,3,4 but whether it is more effective remains unknown.
In 2013, NYU Langone Medical Center (NYULMC) joined the national Bundled Payment for Care Improvement (BPCI) model for patients with Medicare fee-for-service insurance undergoing cardiac valve replacement, major joint replacement in the lower extremities, or spinal fusion.5 The BPCI model held NYULMC accountable for costs incurred from the index admission to 90 days after discharge. To control these costs, NYULMC attempted to shift referrals from facility-based to home-based postacute care. In the context of this shift in referrals, we examined the change in hospital readmission rates.
We used complete claims data provided by Medicare. We divided the study period into 3 phases. Medicare provided baseline data from July 1, 2009, through May 30, 2012, for 3070 patients. Because of superstorm Sandy, NYULMC was closed from October 29 through December 27, 2012. From January 1 through September 30, 2013, NYULMC began preparations for BPCI, but cost incentives were not in effect (preparation period). From October 1, 2013, through August 31, 2014, cost incentives took effect (risk-bearing period) (1594 patients). Inclusion criteria were determined by the BPCI model. This study was approved by the institutional review board of the NYULMC; the institutional review board of the NYU School of Medicine waived the need for patient authorization and consent.
Data were assessed from July 1, 2009, to December 31, 2014. For each condition, we examined whether the risk-bearing period was associated with discharge to postacute care in a facility. We also examined whether the BPCI period was associated with 30-day readmission for each condition. For all models, we used generalized estimating equations, controlled for age, race, sex, and major complications or comorbidity (as determined by a principal diagnosis related group) during the index admission, with clustering at the physician level.
Patient characteristics appear in the Table. Discharge rates to postacute care facilities fell from 454 of 644 patients (70.5%) in the baseline period to 72 of 342 patients (21.1%) in the risk-bearing period (adjusted odds ratio [AOR], 0.11; 95% CI, 0.08-0.15) for cardiac valve surgery, from 1289 of 1908 patients (67.6%) to 343 of 1024 patients (33.5%) (AOR, 0.26; 95% CI, 0.22-0.31) for major joint replacement in the lower extremities, and from 209 of 518 patients (40.3%) to 68 of 228 patients (29.8%) (AOR, 0.69; 95% CI, 0.48-0.97) for spinal fusion surgery (Figure). In these same cohorts, readmission rates were unchanged in patients undergoing cardiac valve surgery (117 [18.2%] vs 54 [15.8%]; AOR, 0.93; 95% CI, 0.67-1.31; P = .69), significantly decreased in patients undergoing joint replacement (152 [8.0%] vs 51 [5.0%]; AOR, 0.66; 95% CI, 0.47-0.92; P = .01), and unchanged in patients undergoing spinal fusion (51 [9.8%] vs 26 [11.4%]; AOR, 1.19; 95% CI, 0.71-1.99; P = .50). Mean length of stay decreased for all conditions from baseline to the risk-bearing period.
We achieved absolute 49% and 34% reductions in rates of discharge to postacute care facilities among patients undergoing cardiac valve surgery and major joint replacement in the lower extremities, respectively, with no corresponding increase in readmission rates. Readmission rates were similarly stable in patients undergoing spinal fusion, for whom rates of admission to postacute care facilities were unchanged.
Our findings suggest that institutions may be able to shift some patients from facility-based to home-based postacute care without adversely affecting hospital readmission rates or the length of hospital stay. Although we did not investigate the mechanism for the major decrease in rates of referral to facility-based postacute care, the inpatient rehabilitation facility owned by NYULMC closed during the risk-bearing period. Such a dramatic decrease may not have occurred without the change in availability of inpatient beds.
A limitation of the study is that we did not examine outcomes such as functional status or quality of life, which merit further investigation. An additional limitation is that the disease burden in the population may have changed during the study period, although we adjusted for the presence of major complications or comorbidities. Our findings raise questions about the value of providing postacute care services in facilities where care is more costly and potentially more disruptive to the lives of patients and families.
Corresponding Author: Lindsay E. Jubelt, MD, MS, Department of Medicine, Icahn School of Medicine, Mount Sinai Health System, One Gustave L. Levy Place, New York, NY 10029 (firstname.lastname@example.org).
Published Online: November 23, 2015. doi:10.1001/jamainternmed.2015.6265.
Author Contributions: Ms Chung had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Jubelt, Goldfeld, Horwitz.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Jubelt.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Jubelt , Goldfeld, Chung.
Administrative, technical, or material support: Jubelt, Chung, Horwitz.
Study supervision: Blecker, Horwitz.
Conflict of Interest Disclosures: Dr Horwitz reports receiving funding from the Centers for Medicare & Medicaid Services (CMS) to develop and maintain quality measures. No other disclosures were reported.
Funding/Support: The data for this project were provided through contract 2106-000 by the CMS Bundled Payment for Care Improvement program. This study was supported by grants K08HS23683 (Dr Blecker) and R01 HS022882 (Dr Horwitz) from the Agency for Healthcare Research and Quality.
Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.