By Karen E. Joynt Maddox, M.D., M.P.H., E. John Orav, Ph.D., Jie Zheng, Ph.D., and Arnold M. By Epstein, M.D.
The New England Journal of Medicine, July 19, 2018
The Center for Medicare and Medicaid Innovation (CMMI) launched the Bundled Payments for Care Improvement (BPCI) initiative in 2013. A subsequent study showed that the initiative was associated with reductions in Medicare payments for total joint replacement, but little is known about the effect of BPCI on medical conditions.
We used Medicare claims from 2013 through 2015 to identify admissions for the five most commonly selected medical conditions in BPCI: congestive heart failure (CHF), pneumonia, chronic obstructive pulmonary disease (COPD), sepsis, and acute myocardial infarction (AMI). We used difference-in-differences analyses to assess changes in standardized Medicare payments per episode of care (defined as the hospitalization plus 90 days after discharge) for these conditions at BPCI hospitals and matched control hospitals.
A total of 125 hospitals participated in BPCI for CHF, 105 hospitals for pneumonia, 101 hospitals for COPD, 88 hospitals for sepsis, and 73 hospitals for AMI. At baseline, the average Medicare payment per episode of care across the five conditions at BPCI hospitals was $24,280, which decreased to $23,993 during the intervention period (difference, −$286; P=0.41). Control hospitals had an average payment for all episodes of $23,901, which decreased to $23,503 during the intervention period (difference, −$398; P=0.08; difference in differences, $112; P=0.79). Changes from baseline to the intervention period in clinical complexity, length of stay, emergency department use or readmission within 30 or 90 days after hospital discharge, or death within 30 or 90 days after admission did not differ significantly between the intervention and control hospitals.
Hospital participation in five common medical bundles under BPCI was not associated with significant changes in Medicare payments, clinical complexity, length of stay, emergency department use, hospital readmission, or mortality. (Funded by the Commonwealth Fund.)
From the Discussion
In summary, hospital participation in five common medical bundles under BPCI, as compared with nonparticipation, was not associated with changes from baseline in total Medicare payments per episode, case complexity, length of stay, emergency department use, hospital readmission, or mortality. Bundling of services to encourage more efficient care has great face validity and enjoys bipartisan support. For such bundling to work for medical conditions, however, more time, new care strategies and partnerships, or additional incentives may be required.
By Don McCanne, M.D.
In discussions of the disappointing results of experiments with alternative payment models, especially accountable care organizations, frequently advocates of these models recommend continuing to tweak them and study them further, but, at the same time, they also express enthusiasm for bundled payments as a promising cost saving and quality improvement tool.
Some surgical interventions, such as joint replacement, bundle into a neat package, and initial results suggest that these bundles can save money (although it remains unclear as to how much cost shifting takes place in the background of an institution offering a great variety of services of varying complexity – how do you allocate the multitude of other operational costs of the institution?).
For bundling to have a significant impact on costs, it would be important to include common major medical disorders since they account for a considerable portion of hospital admissions. This study of five five such disorders showed that bundling “was not associated with changes from baseline in total Medicare payments per episode, case complexity, length of stay, emergency department use, hospital readmission, or mortality.”
As with other reports of failures in innovative payment models the authors suggest “more time, new care strategies and partnerships, or additional incentives” i.e., more tweaking, and study the responses.
All of this is simply resulting in further delay in implementing a model that would actually accomplish the goals of efficiency and cost containment with the additional benefits of true universality, equity, and accessibility – a well designed, single payer, improved Medicare for all. Just think of the difference it would have made if we did this a quarter of a century ago when we began our advocacy. How much longer do we have to diddle around before we finally make our move?
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