HEALTH CARE AND HUMAN SERVICES POLICY, RESEARCH, AND CONSULTING - WITH REAL-WORLD PERSPECTIVE. Impact of Medicare’s Bundled Payments for Care Improvement (BPCI) Initiative on Cost and Quality of Care Laura Dummit, MSPH, Grecia Marrufo, PhD, Jaclyn Marshall, MS, Eleonora Tan, PhD, Aylin Bradley, MA, Karla López de Nava, PhD, The Lewin Group June 25, 2017 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or any of its agencies.
Outline of Presentation Overview of BPCI Analytical Approach Methods and Data Sources Participants Impact of BPCI on Payments and Quality of Care, Model 2 Orthopedic Surgery Cardiovascular Surgery Conclusion The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of www.lewin.com Health and Human Services or any of its agencies.
Overview of BPCI The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of www.lewin.com Health and Human Services or any of its agencies.
Overview: Bundled Payments for Care Improvement (BPCI) Initiative Models 2, 3, 4 The BPCI initiative has multiple layers of complexity that the monitoring and evaluation project must consider in the design and analysis. Models Model 4: Model 2: Retrospective hospital + post Prospective Model 3: Retrospective PAC only bundle acute care (PAC) bundle acute care bundle Episode Inpatient Inpatient Inpatient Inpatient length stay + stay through stay + 60 Initiation of Initiation of Initiation of stay + 90 related 30 days post days post days post PAC to day PAC to day PAC to day readmissions hospital hospital hospital 30 60 90 within 30 discharge discharge discharge days 48 clinical episodes as identified by MS-DRGs Range of approaches by awardees (including ability to use waivers) The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of www.lewin.com Health and Human Services or any of its agencies.
Major Evaluation Questions Nature of the initiative and Explanatory factors participants at baseline Impact of the initiative associated with impact of and over the course of the the initiative initiative • Participants • Impact on utilization and • Characteristics of the payment model • Market characteristics • Impact on quality • Characteristics of the • Patient population participating providers’ characteristics • Other unintended approach to their chosen consequences • Model incentive model structure characteristics • Market and spill-over • Characteristics of the impact • Care redesign and cost participating providers’ saving strategy specific features and characteristics ability to carry out their proposed intervention(s) • Characteristics of the market • Patient population and case mix characteristics The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of www.lewin.com Health and Human Services or any of its agencies.
Analytical Approach The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of www.lewin.com Health and Human Services or any of its agencies.
Methods and Data Sources Mixed methods approach consisting of: Descriptive Analysis Difference in Differences Qualitative Analysis Data Sources Primary Data: Beneficiary survey, site visits, focus groups, expert interviews, awardee-submitted data, technical expert panels Secondary Data: Medicare claims and enrollment data, Patient Assessment data (OASIS, MDS, IRF-PAI), Provider of Services (POS) file, Medicare Provider Enrollment, Chain, and Ownership System (PECOS), and other data The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of www.lewin.com Health and Human Services or any of its agencies.
Study Population for Claim-Based Analysis BPCI Intervention Population : defined by model and clinical episode. Includes all episodes initiated in BPCI-participating providers from October 2013 through September 2014. Comparison Population : selected in 4 steps: Excluded non-participating hospitals whose characteristics were not represented 1. in the BPCI population (e.g., not paid under Medicare’s IPPS) or who could have been influenced by BPCI (e.g. located in markets with high BPCI participation, owned by a BPCI participating organization, or preparing to join BPCI). Each BPCI provider was matched with up to 15 comparison providers based on 2. market and provider characteristics and baseline claims outcomes using propensity score matching or Mahalanobis matching. Constructed episodes for BPCI and matched comparison providers between 3. October 2010 and September 2014. Among the comparison episodes identified in step 3, we drew a random sample to 4. match the distribution of MS-DRGs and quarters of episode start in the BPCI population. The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of www.lewin.com Health and Human Services or any of its agencies.
Participants The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of www.lewin.com Health and Human Services or any of its agencies.
BPCI-participating Hospitals Differ from All Hospitals Non-participating BPCI Hospitals Hospitals (N=110) (N=3,056) N % N % Ownership For Profit 13 12% 672 22% Government 4 4% 550 18% Non-Profit 93 85% 1,803 59% Urban/Rural Rural 6 5% 886 29% Urban 104 95% 2,170 71% Part of Chain 49% 1,528 52% Yes 54 Mean Mean Bed Count 359 188 Number of Admissions for BPCI 4,060 2,140 Episode MS-DRGs, 2011 Medicare Days Percent 37% 41% Resident-to-bed ratio 0.18 0.06 Disproportionate Share Percent 30% 28% Standardized Part A Allowed Payment inpatient stay plus 90 day PDP, 2011 Source: Lewin analysis of 2013 Clinical Episode Group (N, BPCI discharges) Mean Mean Provider of Service (POS) and 2011 Medicare claims. BPCI Orthopedic surgery (38,718) $29,439 $28,882 participating hospitals are Non-surgical other medical (14,577) $26,595 $24,897 defined as Model 2 EIs, Q4 2013 Non-surgical neuro (2,690) $25,235 $24,040 – Q3 2014. Non-participant Non-surgical respiratory (19,818) $24,310 $23,183 hospitals are all other hospitals Non-surgical cardiac (30,290) $22,191 $21,677 and exclude Model 4 hospitals Surgical and non-surgical GI (5,854) $21,935 $20,835 participating in BPCI during the Cardiovascular surgery (18,452) $33,664 $33,513 first year. Spinal surgery (2,504) $29,781 $28,929 The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of Health and Human Services or www.lewin.com any of its agencies.
Impact of BPCI on Payments and Quality of Care, Model 2, Hospital, Orthopedic Surgery The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of www.lewin.com Health and Human Services or any of its agencies.
Total Payments Declined for Orthopedic Surgery Episodes at BPCI Hospitals relative to Comparison Hospitals BPCI (N=17,672) Comparison (N=17,688) Diff-in-Diff estimate Measure Baseline Intervention Baseline Intervention Diff-in-Diff LCI UCI Total Standardized Allowed Payment, Inpatient Anchor $30,239 $28,232 $29,814 $28,670 -$864* -$1,353 -$375 Hospitalization and 90-day PDP *Denotes statistical significance at the 5% level. LCI=lower confidence interval at the 5% level: UCI= upper confidence interval at the 5% level. Note: Baseline is defined as episodes that began Q4 2011 through Q3 2012. Intervention is defined as episodes that began Q4 2013 through Q3 2014. Sample sizes reflect number of episodes initiated during the intervention period that met inclusion criteria for the outcome. Medicare payments are trended and expressed in 2014 dollars. Source: Lewin analysis of Medicare claims and enrollment data for episodes that began Q4 2011 through Q3 2014 for BPCI and comparison providers. The contents of this presentation are solely the responsibility of the authors and do not necessarily represent the official views of the U.S. Department of www.lewin.com Health and Human Services or any of its agencies.
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