The Association between Bundled Payment Participation and Changes in Medical Episode Outcomes among High-Risk Patients

Abstract

Background: Bundled payments for medical conditions are associated with stable quality and savings through shorter skilled nursing facility (SNF) length of stay. However, effects among clinically higher-risk patients remain unknown. Objective: To evaluate whether the association between participation in bundled payments for medical conditions and episode outcomes differed for clinically high-risk versus other patients. Design: Retrospective difference-in-differences analysis; Participants: 471,421 Medicare patients hospitalized at bundled payment and propensity-matched non-participating hospitals. Exposures were 5 measures of clinically high-risk groups: advanced age (>85 years old), high case-mix, disabled, frail, and prior institutional post-acute care provider utilization. Main Measures: Primary outcomes were SNF length of stay and 90-day unplanned readmissions. Secondary outcomes included quality, utilization, and spending measures. Key Results: SNF length of stay was differentially lower among frail patients (aDID −0.4 days versus non-frail patients, 95% CI −0.8 to −0.1 days), patients with advanced age (aDID −0.8 days versus younger patients, 95% CI −1.2 to −0.3 days), and those with prior institutional post-acute care provider utilization (aDID −1.1 days versus patients without prior utilization, 95% CI −1.6 to −0.6 days), compared to non-frail, younger, and patients without prior utilization, respectively. BPCI participation was also associated with differentially greater SNF LOS among disabled patients (aDID 0.8 days versus non-disabled patients, 95% CI 0.4 to 1.2 days, p < 0.001). Bundled payment participation was not associated with differential changes in readmissions in any high-risk group but was associated with changes in secondary outcomes for some groups. Conclusions: Changes under medical bundles affected, but did not indiscriminately apply to, high-risk patient groups.

Keywords: health care payment; health policy.

Figure 1

Adjusted Changes in in SNF LOS for Medical Condition Episodes Among High-Risk Patients (2011–2016). Abbreviations: LOS = length of stay; IRF = Inpatient Rehabilitation Facility; SNF = Skilled Nursing Facility. Advanced age = Age > 85 years old. High Case-Mix = Top 20% of Elixhauser score. Prior IRF/SNF Utilization = Utilization within the preceding 12 months.

Figure 2

Adjusted Changes in 90-Day Unplanned Readmission Rate ^‡ for Medical Condition Episodes Among High-Risk Patients (2011–2016). Abbreviations: IRF = Inpatient Rehabilitation Facility; SNF = Skilled Nursing Facility. ^‡ At least one acute care readmission during the 90-day episode. Advanced age = Age > 85 years old. High Case-Mix = Top 20% of Elixhauser score. Prior IRF/SNF Utilization = Utilization within the preceding 12 months.