Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations

doi:10.1007/s11606-024-08655-4

. 2024 May;39(7):1180-1187.

doi: 10.1007/s11606-024-08655-4. Epub 2024 Feb 6.

Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations

Aidan P Crowley^{1

2

3}, Sarah Neville^{4

5}, Chuxuan Sun⁶, Qian Erin Huang⁶, Deborah Cousins⁶, Torrey Shirk⁶, Jingsan Zhu⁶, Austin Kilaru^{7

8}, Joshua M Liao^{7

9

10}, Amol S Navathe^{6

11

7

12}

Affiliations

¹ Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. aidan.crowley@pennmedicine.upenn.edu.
² Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA. aidan.crowley@pennmedicine.upenn.edu.
³ Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. aidan.crowley@pennmedicine.upenn.edu.
⁴ The Commonwealth Fund, New York, NY, USA.
⁵ Independent Health and Aged Care Pricing Authority, Sydney, Australia.
⁶ Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
⁷ Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
⁸ Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
⁹ Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA.
¹⁰ Program on Policy Evaluation and Learning, UT Southwestern, Dallas, TX, USA.
¹¹ Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA.
¹² Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.

PMID: 38319498
PMCID: PMC11116315 (available on 2025-05-01)
DOI: 10.1007/s11606-024-08655-4

Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations

Aidan P Crowley et al. J Gen Intern Med. 2024 May.

. 2024 May;39(7):1180-1187.

doi: 10.1007/s11606-024-08655-4. Epub 2024 Feb 6.

Authors

Affiliations

¹ Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. aidan.crowley@pennmedicine.upenn.edu.
² Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA. aidan.crowley@pennmedicine.upenn.edu.
³ Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. aidan.crowley@pennmedicine.upenn.edu.
⁴ The Commonwealth Fund, New York, NY, USA.
⁵ Independent Health and Aged Care Pricing Authority, Sydney, Australia.
⁶ Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
⁷ Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
⁸ Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
⁹ Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA.
¹⁰ Program on Policy Evaluation and Learning, UT Southwestern, Dallas, TX, USA.
¹¹ Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA.
¹² Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.

PMID: 38319498
PMCID: PMC11116315 (available on 2025-05-01)
DOI: 10.1007/s11606-024-08655-4

Abstract

Background: Medicare's voluntary bundled payment programs have demonstrated generally favorable results. However, it remains unknown whether uneven hospital participation in these programs in communities with greater shares of minorities and patients of low socioeconomic status results in disparate access to practice redesign innovations.

Objective: Examine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced).

Design: Cross-sectional study using ordinary least squares regression controlling for patient and community factors.

Participants: Medicare fee-for-service patients enrolled from 2015-2017 (pre-BPCI-Advanced) and residing in 2,058 local communities nationwide defined by Hospital Service Areas (HSAs). Each community's share of marginalized patients was calculated separately for each of the share of beneficiaries of Black race, Hispanic ethnicity, or dual eligibility for Medicare and Medicaid.

Main measures: Dichotomous variable indicating whether a given community had at least one hospital that ever participated in BPCI-Advanced from 2018-2022.

Key results: Communities with higher shares of dual-eligible individuals were less likely to be served by a hospital participating in BPCI-Advanced than communities with the lowest quartile of dual-eligible individuals (Q4: -15.1 percentage points [pp] lower than Q1, 95% CI: -21.0 to -9.1, p < 0.001). There was no consistent significant relationship between community proportion of Black beneficiaries and likelihood of having a hospital participating in BPCI-Advanced. Communities with higher shares of Hispanic beneficiaries were more likely to have a hospital participating in BPCI-Advanced than those in the lowest quartile (Q4: 19.2 pp higher than Q1, 95% CI: 13.4 to 24.9, p < 0.001).

Conclusions: Communities with greater shares of dual-eligible beneficiaries, but not racial or ethnic minorities, were less likely to be served by a hospital participating in BPCI-Advanced Policymakers should consider approaches to incentivize more socioeconomically uniform participation in voluntary bundled payments.

Keywords: alternative payment models; bundled payments; health equity.

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Conflict of interest statement

Dr. Navathe reports grants from Hawaii Medical Service Association, grants from Commonwealth Fund, grants from Robert Wood Johnson Foundation, grants from Donaghue Foundation, grants from the Veterans Affairs Administration*, grants from Arnold Ventures, grants from United Healthcare, grants from Blue Cross Blue Shield of NC, grants from Humana, personal fees from Navvis Healthcare, personal fees from Elsevier Press, personal fees from Medicare Payment Advisory Commission, personal fees from Analysis Group, personal fees from Advocate Physician Partners, personal fees from the Federal Trade Commission, personal fees from Catholic Health Services Long Island, and equity from Clarify Health, personal fees and board membership for The Scan Group, and non-compensated board membership for Integrated Services, Inc. outside the submitted work in the past 3 years. Dr. Liao reports honoraria from Marcus Evans, Comagine Health, and Brown University outside the submitted work. Dr. Neville reports payments from the Commonwealth Fund and the Independent Health and Aged Care Pricing Authority of Australia and consulting fees from Capadev LLP. All other authors declare no conflicts of interest.

References

1. What Are Bundled Payments? NEJM Catalyst. 2018. 10.1056/CAT.18.0247
1. Joynt Maddox KE, Orav EJ, Zheng J, Epstein AM. Year 1 of the Bundled Payments for Care Improvement–Advanced Model. N Engl J Med. 2021;385(7):618-627.10.1056/NEJMsa2033678. - PMC - PubMed
1. Joynt Maddox KE, Orav EJ, Zheng J, Epstein AM. Evaluation of Medicare’s Bundled Payments Initiative for Medical Conditions. N Engl J Med. 2018;379(3):260-269.10.1056/NEJMsa1801569. - PubMed
1. CMS Bundled Payments for Care Improvement Advanced Model: Third Evaluation Report. Lewin Group 2022:1–84. Accessed January 14, 2023. https://innovation.cms.gov/data-and-reports/2022/bpci-adv-ar3.
1. Liao JM, Ibrahim SA, Huang Q, et al. The Proportion of Marginalized Individuals in US Communities and Hospital Participation in Bundled Payments. Popul Health Manag. 2022;25(4):501–508. (In eng). 10.1089/pop.2021.0334. - PMC - PubMed

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[1] What Are Bundled Payments? NEJM Catalyst. 2018. 10.1056/CAT.18.0247

[2] What Are Bundled Payments? NEJM Catalyst. 2018. 10.1056/CAT.18.0247

[3] Joynt Maddox KE, Orav EJ, Zheng J, Epstein AM. Year 1 of the Bundled Payments for Care Improvement–Advanced Model. N Engl J Med. 2021;385(7):618-627.10.1056/NEJMsa2033678. - PMC - PubMed

[4] Joynt Maddox KE, Orav EJ, Zheng J, Epstein AM. Year 1 of the Bundled Payments for Care Improvement–Advanced Model. N Engl J Med. 2021;385(7):618-627.10.1056/NEJMsa2033678. - PMC - PubMed

[5] Joynt Maddox KE, Orav EJ, Zheng J, Epstein AM. Evaluation of Medicare’s Bundled Payments Initiative for Medical Conditions. N Engl J Med. 2018;379(3):260-269.10.1056/NEJMsa1801569. - PubMed

[6] Joynt Maddox KE, Orav EJ, Zheng J, Epstein AM. Evaluation of Medicare’s Bundled Payments Initiative for Medical Conditions. N Engl J Med. 2018;379(3):260-269.10.1056/NEJMsa1801569. - PubMed

[7] CMS Bundled Payments for Care Improvement Advanced Model: Third Evaluation Report. Lewin Group 2022:1–84. Accessed January 14, 2023. https://innovation.cms.gov/data-and-reports/2022/bpci-adv-ar3.

[8] CMS Bundled Payments for Care Improvement Advanced Model: Third Evaluation Report. Lewin Group 2022:1–84. Accessed January 14, 2023. https://innovation.cms.gov/data-and-reports/2022/bpci-adv-ar3.

[9] Liao JM, Ibrahim SA, Huang Q, et al. The Proportion of Marginalized Individuals in US Communities and Hospital Participation in Bundled Payments. Popul Health Manag. 2022;25(4):501–508. (In eng). 10.1089/pop.2021.0334. - PMC - PubMed

[10] Liao JM, Ibrahim SA, Huang Q, et al. The Proportion of Marginalized Individuals in US Communities and Hospital Participation in Bundled Payments. Popul Health Manag. 2022;25(4):501–508. (In eng). 10.1089/pop.2021.0334. - PMC - PubMed

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Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations

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Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations

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