Bundled Payments Tied to Reduced Spending With Less Skilled Nursing Utilization

By Lisa Rappaport

July 16, 2020

(Reuters Health) - Medicare bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, and pneumonia are associated with reduced spending and less use of skilled nursing, a U.S. study suggests.

Researchers examined Medicare claims data for these four conditions at 226 hospitals that participated in Medicare's bundled payments for care (BCPI) initiative and 700 hospitals that didn't participate. They compared per-episode spending and 90-day mortality for a baseline period from January 2011 to September 2013 and a treatment period from October 2013 to December 2016.

For BCPI hospitals, the analysis included 261,163 episodes of care in the baseline period and 93,562 in the treatment period; it also included 211,208 episodes in the baseline period and 78,643 episodes in the treatment period for the non-BCPI hospitals.

Total spending per episode decreased from $18,995 during the baseline period to $18,771 in the treatment period at BCPI hospitals in unadjusted analysis, and from $18,849 to $18797 for non-BCPI hospitals. In adjusted analysis, this translated into a differential decrease in total episode spending of 1.2%.

"Prior to this study, we had independent, peer-reviewed evidence that Medicare bundled payments were effective in reducing spending while maintaining quality for hip and knee replacement surgery," said senior study author Dr. Amol Navathe, an assistant professor of health policy and medicine at the University of Pennsylvania in Philadelphia.

"This is the first study to demonstrate that they are associated with reduced spending for medical conditions like heart attacks, congestive heart failure exacerbations, or pneumonia, while preserving clinical outcomes," Dr. Navathe said by email.

Differences in spending on skilled nursing after discharge appear to have impacted the differences in total per-episode spending, researchers report in The BMJ.

For BCPI hospitals, the differential decrease in spending on skilled nursing was 6.3% and the differential decrease in outpatient professional fees was 10.4%. At the same time, the differential increase in spending on home health services was 4.4%.

Bundled payments seem to work because participating hospitals pay more attention to what happens after they discharge a patient, Dr. Navathe said.

"Our findings suggest that hospitals that discharged patients to skilled nursing facilities (SNFs) were successful in reducing how long patients stayed in them before going home - either by selecting SNFs that were more judicious in care or by partnering with them to determine how quickly a patient could safely be discharged," Dr. Navathe added.

This appeared to reduce per-episode spending without resulting in lower quality care, based on the analysis of 90-day mortality rates.

In the unadjusted analysis, 90-day mortality decreased from 12.5% to 12% from baseline to the treatment period in the BCPI group, and increased from 11.2% to 11.4% in the non-BCPI hospitals. However, in adjusted analysis there was no meaningful difference in changes in 90-day mortality.

One limitation of the study is that it didn't look at other quality measures, including assessments of symptom management and functional status for individual patients, the study team notes.

While mortality is one valid quality metric, there are a broad scope of quality measures available that were not used in the study, noted Dr. Jennifer Goldstein, a physician and scientist with ChristianaCare's Value Institute in Newark, Delaware, and an associate professor at Sidney Kimmel Medical College in Philadelphia.

"Interventions such as bundled payment innovations take time to gain traction and may have different outcomes on spending and quality depending on different patient populations," Dr. Goldstein, who wasn't involved in the study, said by email.

"Further studies will need to take a closer look at the cascade of changes that bundled payment structures influence, particularly processes of care, and more specific patient outcomes," Dr. Goldstein said.

SOURCE: https://bit.ly/38Y6wQQ The BMJ, online June 17, 2020.