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Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations

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Abstract

Background

Medicare’s voluntary bundled payment programs have demonstrated generally favorable results. However, it remains unknown whether uneven hospital participation in these programs in communities with greater shares of minorities and patients of low socioeconomic status results in disparate access to practice redesign innovations.

Objective

Examine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced).

Design

Cross-sectional study using ordinary least squares regression controlling for patient and community factors.

Participants

Medicare fee-for-service patients enrolled from 2015–2017 (pre-BPCI-Advanced) and residing in 2,058 local communities nationwide defined by Hospital Service Areas (HSAs). Each community’s share of marginalized patients was calculated separately for each of the share of beneficiaries of Black race, Hispanic ethnicity, or dual eligibility for Medicare and Medicaid.

Main Measures

Dichotomous variable indicating whether a given community had at least one hospital that ever participated in BPCI-Advanced from 2018–2022.

Key Results

Communities with higher shares of dual-eligible individuals were less likely to be served by a hospital participating in BPCI-Advanced than communities with the lowest quartile of dual-eligible individuals (Q4: -15.1 percentage points [pp] lower than Q1, 95% CI: -21.0 to -9.1, p < 0.001). There was no consistent significant relationship between community proportion of Black beneficiaries and likelihood of having a hospital participating in BPCI-Advanced. Communities with higher shares of Hispanic beneficiaries were more likely to have a hospital participating in BPCI-Advanced than those in the lowest quartile (Q4: 19.2 pp higher than Q1, 95% CI: 13.4 to 24.9, p < 0.001).

Conclusions

Communities with greater shares of dual-eligible beneficiaries, but not racial or ethnic minorities, were less likely to be served by a hospital participating in BPCI-Advanced Policymakers should consider approaches to incentivize more socioeconomically uniform participation in voluntary bundled payments.

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Funding

This work was funded by the National Institute on Minority Health and Health Disparities (R01-MD013859 and R01-MD015055) and Agency for Health Research and Quality (R01HS027595). Dr. Kilaru received support from the Agency for Healthcare Research and Quality (5K12HS026372-04). Sponsors did not have any role in the research.

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Authors and Affiliations

  1. Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Aidan P. Crowley BS, Chuxuan Sun MPA, Qian Erin Huang MPH, Deborah Cousins MS, Torrey Shirk BA, Jingsan Zhu MS, MBA & Amol S. Navathe MD, PhD

  2. Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA

    Aidan P. Crowley BS & Amol S. Navathe MD, PhD

  3. Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA

    Aidan P. Crowley BS, Austin Kilaru MD, MS, Joshua M. Liao MD, MSc & Amol S. Navathe MD, PhD

  4. The Commonwealth Fund, New York, NY, USA

    Sarah Neville PhD

  5. Independent Health and Aged Care Pricing Authority, Sydney, Australia

    Sarah Neville PhD

  6. Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA

    Austin Kilaru MD, MS

  7. Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA

    Joshua M. Liao MD, MSc

  8. Program on Policy Evaluation and Learning, UT Southwestern, Dallas, TX, USA

    Joshua M. Liao MD, MSc

  9. Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA

    Amol S. Navathe MD, PhD

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  1. Aidan P. Crowley BS
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  8. Austin Kilaru MD, MS
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  9. Joshua M. Liao MD, MSc
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Corresponding author

Correspondence to Aidan P. Crowley BS.

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Conflicts of Interest:

Dr. Navathe reports grants from Hawaii Medical Service Association, grants from Commonwealth Fund, grants from Robert Wood Johnson Foundation, grants from Donaghue Foundation, grants from the Veterans Affairs Administration*, grants from Arnold Ventures, grants from United Healthcare, grants from Blue Cross Blue Shield of NC, grants from Humana, personal fees from Navvis Healthcare, personal fees from Elsevier Press, personal fees from Medicare Payment Advisory Commission, personal fees from Analysis Group, personal fees from Advocate Physician Partners, personal fees from the Federal Trade Commission, personal fees from Catholic Health Services Long Island, and equity from Clarify Health, personal fees and board membership for The Scan Group, and non-compensated board membership for Integrated Services, Inc. outside the submitted work in the past 3 years. Dr. Liao reports honoraria from Marcus Evans, Comagine Health, and Brown University outside the submitted work. Dr. Neville reports payments from the Commonwealth Fund and the Independent Health and Aged Care Pricing Authority of Australia and consulting fees from Capadev LLP. All other authors declare no conflicts of interest.

Disclaimer

This article does not necessarily represent the views of the US government or the Department of Veterans Affairs.

Prior presentations

  1. 1.

    Society of General Internal Medicine Annual Meeting. Aurora, CO. May 11, 2023.

  2. 2.

    AcademyHealth Annual Research Meeting. Seattle, WA. June 26, 2023.

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Crowley, A.P., Neville, S., Sun, C. et al. Differential Hospital Participation in Bundled Payments in Communities with Higher Shares of Marginalized Populations. J GEN INTERN MED (2024). https://doi.org/10.1007/s11606-024-08655-4

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