The effects of bundled payment on acute cardiovascular outcomes among older adults

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PROJECT SUMMARY Coronary artery disease causes over 360,000 annual deaths, primarily among older adults, and over $100 billion in medical expenditures. Despite improvements in outcomes, treatment remains beset by unwarranted variation in care coupled with underuse of high-value care. To address these problems, CMS has introduced several bundled payment reforms focused on cardiac procedures, including PCI and CABG. The most recent program – Bundled Payment for Care Improvement Advanced (BPCI-A) – is a voluntary program that creates incentives for hospitals to improve patient outcomes and reduce spending across a 90-day post-discharge episode. Despite the promise of bundled payment, its effects on outcomes for common cardiac procedures are not well understood. Incentives to improve care coordination and quality may encourage hospitals to reduce periprocedural complications and tightly manage post-acute care referrals. At the same time, incentives to reduce spending may encourage hospitals to avoid higher severity patients. In this context, we propose the following aims: Aim 1. Evaluate the role of hospital and patient selection related to PCI and CABG episodes in BPCI-A. We will link hospital participation in BPCI-A with Medicare data and data from the CathPCI and Society of Thoracic Surgeons Adult Cardiac Surgery registries. We will compare hospital and patient severity profiles with claims alone (the status quo in BPCI-A) and claims supplemented with registry data (the gold standard). We will then test whether hospitals with 1) lower claims-based severity compared to registry-based severity were less likely to participate in BPCI-A; and 2) patients with lower claims-based severity became less likely to be treated at participating hospitals after BPCI-A. Aim 2. Evaluate the effects of BPCI-A on periprocedural and post-discharge outcomes. Using Medicare claims and linked data from thousands of hospitals participating in the registries, we will estimate econometric models to test whether BPCI-A was associated with improvements in periprocedural complications and post-discharge outcomes. Aim 3. Evaluate how changes in BPCI-A and delivery system disruptions from COVID-19 inform the future design of bundled payment. We will exploit a change in the design of BPCI-A to examine whether including spending associated with cardiac rehabilitation in the episode led to lower cardiac rehabilitation. We will also compare hospital quality performance using claims-based and registry-based measures and test for shifts in patient severity profiles for patients receiving inpatient and outpatient PCI. Finally, we will examine the accuracy of target prices before and after COVID-19. This proposal is significant because it will be the first to understand the effects of BPCI-A on selection and outcomes for cardiac procedures using high quality registry data. The proposal is innovative in its use of novel data linkages and statistical methods to understand the impact of this critical policy question affecting millions of older adults with coronary artery disease.