Learning and the "early Joiner" Effect for Medical Conditions in Medicare's Bundled Payments for Care Improvement Program: Retrospective Cohort Study

Background:Studies of medical conditions in the Bundled Payments for Care Improvement (BPCI) initiative did not show reductions in Medicare payments for the majority of conditions, but this could mask heterogeneity.Objective:To determine whether earlier enrollment and/or longer participation in BPCI were associated with performance.Design:We divided BPCI hospitals into wave 1 (joined 10/1/13, 1/1/14, or 4/1/14), wave 2 (joined 7/1/14, 10/1/14, 1/1/15, or 4/1/15), and wave 3 (joined 7/1/15, 10/1/15, or 1/1/16) and compared changes in Medicare payments for acute myocardial infarction, heart failure, pneumonia, sepsis, and chronic obstructive pulmonary disease between BPCI and matched controls in 6-month increments.Subjects:US hospitals.Measures:Medicare payments.Results:There were 120 hospital-condition pairs in wave 1, 264 in wave 2, and 300 in wave 3. Wave 1 hospitals had similar savings to controls early in the program (0-6 mo difference in differences-$10, P=0.976; 6-12 mo +$295, P=0.441; 12-18 mo-$540, P=0.218; 18-24 mo-$485, P=0.259) but had greater savings than controls at 24-30 months (difference in differences-$663, P=0.035). Wave 2 (0-6 mo +$193, P=0.524; 6-12 mo-$183, P=0.489; 12-18 mo-$162, P=0.618) and wave 3 hospitals (0-6 mo +$79, P=0.753; 6-12 mo-$32, P=0.876) did not achieve significant savings at any time interval. There were no differential changes in patient outcomes over time.Conclusions:Hospitals that joined BPCI earliest began to achieve savings at roughly 2 years of participation. These findings have implications for this and other alternative payment models.