Bundled Payment Programs and Changes in Practice Patterns and Episode Spending in Major Gastrointestinal Surgery

To evaluate the association between enrollment in the Bundled Payments for Care Improvement -Advanced (BPCI-A) program and changes in utilization of minimally invasive surgery and 90-day episode spending for patients undergoing major gastrointestinal surgery. We compared hospitals that voluntarily enrolled in BPCI-A to control hospitals that did not participate. We used entropy balancing to reweight controls to match the BPCI-A cohort based on observable patient and hospital characteristics. We then used a difference-in-differences approach to estimate the association between surgical approach and 90-day episode payments. We used Medicare claims and American Hospital Association data between 2013 and 2021 to evaluate whether hospital enrollment in the BPCI-A program was associated with changes in 90-day episode spending and utilization of minimally invasive surgical approaches. Using entropy balancing, we reweighted the control group to achieve covariate balance with beneficiaries who obtained care at BPCI-A program hospitals. We performed a difference-in-differences analysis using multivariable linear and generalized linear models, adjusting for patient demographics, comorbidities, and hospital characteristics, with standard errors clustered at the hospital-year level to evaluate these outcomes. Changes in 90-day episode payments at BPCI-A program hospitals versus non-program hospitals were not significantly different (-$172, 95% CI: -$1104 to $760). In comparing trends at BPCI-A program and control hospitals, we identified no significant differences in utilization trends for minimally invasive surgical approaches (relative risk difference: -0.003, 95% CI: -0.10 to 0.04). The similarity in utilization trends between BPCI-A program and control hospitals was observed in the context of increasing overall utilization of MIS approaches from 40.3 to 38.4 to 43.9 to 42.9 during the study period, respectively. We found no evidence that hospitals participating in BPCI-A's major bowel surgery episodes led to differences in episode spending or utilization of minimally invasive surgical approaches.