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

Aidan P Crowley; Sarah Neville; Chuxuan Sun; Qian Erin Huang; Deborah Cousins; Torrey Shirk; Jingsan Zhu; Austin Kilaru; Joshua M Liao; Amol S Navathe

doi:10.1007/s11606-024-08655-4

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

J Gen Intern Med. 2024 Feb 6. doi: 10.1007/s11606-024-08655-4. Online ahead of print.

Authors

Aidan P Crowley^{1

2

3}, Sarah Neville^{4

5}, Chuxuan Sun⁶, Qian Erin Huang⁶, Deborah Cousins⁶, Torrey Shirk⁶, Jingsan Zhu⁶, Austin Kilaru^{7

8}, Joshua M Liao^{7

9

10}, Amol S Navathe^{6

11

7

12}

Affiliations

¹ Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. aidan.crowley@pennmedicine.upenn.edu.
² Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA. aidan.crowley@pennmedicine.upenn.edu.
³ Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA. aidan.crowley@pennmedicine.upenn.edu.
⁴ The Commonwealth Fund, New York, NY, USA.
⁵ Independent Health and Aged Care Pricing Authority, Sydney, Australia.
⁶ Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
⁷ Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
⁸ Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
⁹ Department of Medicine, UT Southwestern Medical Center, Dallas, TX, USA.
¹⁰ Program on Policy Evaluation and Learning, UT Southwestern, Dallas, TX, USA.
¹¹ Department of Health Care Management, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA.
¹² Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.

PMID: 38319498
DOI: 10.1007/s11606-024-08655-4

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.

Keywords: alternative payment models; bundled payments; health equity.

Abstract

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