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

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.

Automated summary

The association between participation in bundled payments for medical conditions and episode outcomes varies for clinically high-risk patients versus other patients. While participation is associated with lower skilled nursing facility length of stay for frail patients, patients with advanced age, and those with prior institutional post-acute care provider utilization, it is associated with higher length of stay for disabled patients. Bundled payment participation does not have a differential impact on readmissions for high-risk groups.