Safety-net hospitals (SNHs) and smaller facilities were less likely to participate in the voluntary Bundled Payments for Care Improvement (BPCI) programs for cardiac services than larger centers with catheterization laboratories, Harvard researchers reported in JAMA Cardiology. These findings indicate that the outcomes observed from these programs may not be broadly applicable.
“Selective participation represents a potential threat to the external validity of voluntary programs, including BPCI,” wrote corresponding author Daniel M. Blumenthal, MD, MBA, and colleagues. “Investigating participation bias in BPCI Model 2 cardiac bundles is critical for understanding the generalizability of cost and quality outcomes from this pilot and may help policymakers mitigate this bias when designing and implementing future programs, such as BPCI Advanced, a voluntary bundled payment pilot CMS plans to launch in October 2018.”
The researchers compared 159 hospitals voluntarily participating in BPCI model 2 bundles for acute myocardial infarction (AMI), congestive heart failure (CHF), coronary artery bypass graft or percutaneous coronary intervention to a control group of 1,240 nonparticipating hospitals.
Participating hospitals were likely to be larger and served a lower proportion of Medicaid patients. Compared to nonparticipating centers, they were also more likely to:
- Have a cardiac intensive care unit (45.3 percent versus 25.4 percent).
- Offer cardiac surgery on site (62.9 percent versus 29.9 percent).
- Have a cardiac cath lab (88.1 percent versus 51.9 percent).
- Have lower risk-standardized 30-day mortality rates for AMI (13.7 percent versus 16.6 percent) and CHF (11.3 percent versus 12.4 percent).
In multivariable analysis, being a SNH was associated with 70 percent reduced odds in bundle participation. SNHs were defined as those with disproportionate sharepayments in the top 10 percent of hospitals nationally.
Blumenthal and colleagues said future voluntary bundled payment models may continue struggling to attract smaller centers and SNHs if they don’t overcome the limitations of BPCI model 2.
“Smaller hospitals may be less likely to participate in voluntary programs because they treat lower volumes of common cardiovascular diseases, lack the capabilities to treat severe and complex cardiovascular disease, and do not possess the administrative and quality improvement infrastructure to track and rapidly improve performance,” the researchers wrote. “Additionally, SNHs treat outsized proportions of poor and underserved patients, and bundled payment risk adjustment methods do not account for social risk factors.”
Blumenthal et al. said adjusting for these social determinants of health would be one way to make these models more accessible to SNHs. Other options include limiting the downside risk for underrepresented hospitals to encourage participation or creating separate tracks for SNHs and large, non-SNH centers.
CMS could also mandate participation—which HHS secretary Alex Azar has indicated he would support—but the authors cautioned that payment adjustment for social factors would still be necessary to help SNHs succeed in the models.
In an invited commentary, Karen E. Joynt Maddox, MD, MPH, agreed with the authors’ assertion that the results of the cardiac bundles in BPCI model 2 aren’t generalizable to the whole country based on significant differences between participants and non-participants. But there’s still plenty to be learned from studying what happened at hospitals that did participate, she said.
“From early BPCI participants we can learn what highly resourced, high-volume hospitals do when given strong financial incentives to improve quality and cut costs,” wrote Joynt Maddox, with Washington University School of Medicine in St. Louis. “Because hospitals are already paid a fixed price per admission under the diagnosis-related group system, the major opportunities for reducing spending lie in designing innovative approaches to limiting postacute care and reducing readmissions.”
Examples include providing automatic referrals to cardiac rehabilitation and increasing the use of radial access PCI. Examination of bundle outcomes may also offer information on whether certain payment models incentivize providers to change their behavior (for better or worse).
“We do not make cholesterol guidelines based solely on comparisons of outcomes among individuals who elect to take a statin (versus) those who do not, and we should not scale payment models nationwide based solely on comparisons between hospitals that participate (versus) those that do not,” Joynt Maddox wrote. “But we should not miss out on the opportunity to use this program to learn more about the potential for innovative care redesign efforts, or for unintended consequences, under a new paradigm of financial incentives.”