A new study adds fuel to a crucial debate in the ongoing push away from volume and toward value: whether paying a set price for a procedure drives hospitals and doctors simply to perform more of them.
Providers that volunteered to participate in the CMS Innovation Center's Bundled Payments for Care Improvement initiative did not perform more procedures under the value-based payment model, according to a study published Wednesday by the Altarum Institute.
The researchers sought to lay that question to rest, said Francois de Brantes, one of the authors, who is vice president and director of Altarum Institute's Center for Payment Innovation. In particular, he said, they wanted to respond to an editorial penned by a prominent thought leader in health policy in September, which argued that BPCI would stimulate physicians to perform unnecessary treatment.
“We wanted to get to the bottom of the data,” de Brantes said. He and co-authors Andrew Wilson, also from the Center for Payment Innovation, and Dr. Patrick Conway, the CMS' chief medical officer, examined total hip and knee replacement procedures at hospitals that participated in the BPCI program and those that did not. They found that the change in volume between the two was not statistically significant.
The Bundled Payments for Care Improvement initiative is a voluntary program developed to test whether paying a set fee for all the care associated with a procedure can lower costs and improve quality. It has been implemented in phases since 2013. Participants can choose from 48 clinical episodes, including total hip and knee replacements, the hospitalizations for which cost Medicare more than $7 billion in 2014.
The first year of the program delivered mixed results, with "modest reductions" in Medicare payments for some clinical episodes. In some cases, quality improved, and in others, it declined, according to a CMS report released in September.
BPCI is different from the Comprehensive Care for Joint Replacement model, another initiative of the Innovation Center that bundles payments for hip and knee replacements. CJR, which began April 1, 2016, is mandatory for 800 hospitals across 67 geographic areas of the U.S.
Altarum's analysis is limited to the volume of total joint replacements reimbursed under the BPCI program compared with nonparticipants. It found that the average annual number performed by the 29 BPCI providers they examined was slightly higher than the number performed by 2,592 others. But the percentage change in procedures from the years before and after the initiative started was greater among the nonparticipants.
The researchers concluded that the changes in volume were not statistically significant. From 2010 to 2015, the number of procedures rose 7.3% at BPCI participants, compared with 9.6% among nonparticipants. From 2011 to 2015, the number of procedures grew 11.4% among BPCI participants and 12.1% among nonparticipants.
De Brantes acknowledged the vast difference in sample sizes, but stood by the study's conclusions.
The results do not necessarily suggest that bundling payments for a procedure will not lead to higher volume, especially if such episodic payment models are mandatory. Because BPCI is voluntary, participants are self-selecting and thus not a representative sample of all providers. “If you don't think you'd succeed in them, there's no reason to participate,” de Brantes said. It is possible that if it became mandatory, the results would look different, he added.
The study uncovered other important findings as well. It found, for example, that black patients had fewer hip and knee replacements in a given hospital region than whites did. “That speaks to the disparities we know exist in the U.S., and that we have to collectively find a way to better address them,” de Brantes said.