Dan Blumenthal, MD, MBA Assistant in Medicine, Division of Cardiology Massachusetts General Hospital Instructor in Medicine Harvard Medical School

Safety Net and Smaller Hospitals Not Well Represented in Medicare’s Bundled Payment Program for Heart Disease

MedicalResearch.com Interview with:

Dan Blumenthal, MD, MBA Assistant in Medicine, Division of Cardiology Massachusetts General Hospital Instructor in Medicine Harvard Medical School

Dr. Blumenthal

Dan Blumenthal, MD, MBA
Assistant in Medicine, Division of Cardiology
Massachusetts General Hospital
Instructor in Medicine
Harvard Medical School 

MedicalResearch.com: What is the background for this study?

Response: Despite dramatic advances in the treatment of cardiovascular disease (CVD) over the past half-century, CVD remains a leading cause of death and health care spending in the United States (US) and worldwide. More than 2000 Americans die of CVD each day, and more than $200 billion dollars is spent on the treatment of CVD each year in the US By 2030, over 40% of the US population is projected to have some form of CVD, at a cost of $1 trillion to the US economy.

The tremendous clinical and financial burden of cardiovascular illness has helped motivated policymakers to develop policy tools that have the potential to improve health care quality and curb spending.  Alternative payment models, and specifically bundled payments—lump sum payment for defined episodes of care which typically subsume an inpatient hospitalization and some amount of post-acute care—represent a promising tool for slowing health care spending and improving health care value.

Despite broad interest in implementing bundled payments to achieve these aims, our collective understanding of the effects of bundled payments on .cardiovascular disease care quality and spending, and the factors associated with success under this payment model, are limited.

Medicare’s Bundled Payments of Care Improvement (BPCI) is an ongoing voluntary, national pilot program evaluating bundled payments for 48 common conditions and procedures, including several common cardiovascular conditions and interventions.   In this study, we compared hospitals that voluntarily signed up for the four most commonly subscribed cardiac bundles—those for acute myocardial infarction, congestive heart failure, coronary artery bypass graft surgery, and percutaneous coronary intervention—with surrounding control hospitals in order to gain some insight into the factors driving participation, and to assess whether the hospitals participating in these bundles were broadly representative of a diverse set of U.S. acute care hospitals. 

MedicalResearch.com: What are the main findings?

Response: We found significant differences between Medicare’s Bundled Payments of Care Improvement cardiac bundle participants and comparison hospitals with respect to key cardiac capabilities and mortality rates for common cardiovascular conditions.

Specifically, our unadjusted comparisons of BPCI participants and non-participating control hospitals revealed that BPCI participants were larger, more likely to be privately owned or teaching hospitals, had higher AMI and CHF discharge volumes and were more likely to have cardiac intensive care units and cardiac catheterization labs. BPCI participants also had lower risk-standardized 30-day mortality rates for both AMI and CHF.

After multivariable adjustment, hospitals participating in Medicare’s Bundled Payments of Care Improvements cardiac bundles were significantly more likely to be larger, non-safety net hospitals with cardiac catheterization laboratories.

MedicalResearch.com: What should readers take away from your report?

Response: Our main findings indicate that BPCI cardiac bundle participants were not broadly representative of all US acute care hospitals and that selection bias may limit the generalizability of cost and quality outcomes data from the BPCI’s cardiac bundles. Specifically, small and safety net hospitals with more limited cardiac capabilities are not well represented in this pilot program.

MedicalResearch.com: What recommendations do you have for future research as a result of this work?

Response: This work has important implications for the design of future alternative payment programs.  Specifically, our findings highlight the need to design mechanisms for promoting enrollment of a broadly representative cohort of hospitals in future alternative payment model pilots, including bundled payments.  Moreover, our work suggests that we should be cautious in how we use cost and quality outcomes data from the BPCI’s cardiac bundles to justify broader uptake of bundled payments for cardiac conditions, particularly among cohorts of hospitals which were not well represented in this pilot program.  Finally, Medicare plans to implement a new voluntary Bundled Payment Pilot Program called BPCI Advanced on October 1, 2018.  Close, ongoing evaluation of the types of hospitals which choose to participate in BPCI Advanced, including attrition rates and the characteristics of hospitals which choose to drop out of this program over time, will be very important for interpreting and contextualizing clinical and financial outcomes under this new program.

I have no relevant conflicts to disclose.  


Oseran AS, Howard SE, Blumenthal DM. Factors Associated With Participation in Cardiac Episode Payments Included in Medicare’s Bundled Payments for Care Improvement Initiative. JAMA Cardiol. Published online June 27, 2018. doi:10.1001/jamacardio.2018.1736

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Last Updated on June 28, 2018 by Marie Benz MD FAAD