Bundled Payments for Care Improvement and Quality of Care Outcomes in HF

Quick Takes

  • The Centers for Medicare & Medicaid Services BPCI program incentivized hospitals to provide quality HF patient management by paying a fee-for-service process and then shared savings or required reimbursement by the hospital depending on how the total cost of an episode of care compared with a target price.
  • The BPCI program was not associated with an improvement in the 30-day or 90-day rates of readmission or mortality of HF patients.
  • Hospitals participating in the BCPI program had no significant change in GWTG-HF process-of-care measures except they were less likely to provide beta-blockers at discharge.

Study Questions:

Can incentivized Bundled Payments for Care Improvement (BCPI) programs improve the quality of care or all-cause mortality for patients hospitalized with heart failure (HF)?


This cross-sectional study, using a difference-in-difference approach, evaluated data collected from the American Heart Association Get With The Guidelines–Heart Failure (GWTG-HF) registry and the Centers for Medicare & Medicaid Services (CMS) Medicare claims from 23 hospitals participating in the BPCI program versus 224 same-state hospitals not participating in the BPCI program (non-BCPI) between November 1, 2008 and August 31, 2018. Primary endpoints included seven quality-of-care measures. Secondary endpoints included nine outcome measures, including in-hospital mortality and hospital-level risk-adjusted 30-day and 90-day all-cause readmission rate and mortality rate.


Overall study data found that in the BPCI hospital patients (n = 8,721) and non-BPCI hospital patients (n = 94,530), 29.8% were ≤75 years old; 52.9% were female, and 35.7% had left ventricular ejection fraction (LVEF) ≤40%. BPCI hospitals were significantly more likely to be a teaching hospital, located in Western rural areas, and without a heart transplant center.

BPCI participation was not associated with a significant likelihood of improvement in process-of-care measures, except for a lesser likelihood to use a beta-blocker at discharge (adjusted odds ratio [aOR], 0.63; 95% confidence interval [CI], 0.41-0.98; p = 0.04). BPCI participation was not associated with a significant improvement in likelihood of receiving at discharge angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors or aldosterone antagonist; nor of having counseling or placement of cardiac resynchronization therapy (CRT)–pacemaker or CRT–defibrillator (ICD) at discharge. BPCI participation was not associated with an improvement in the provision of 60 minutes of HF education nor of having a follow-up visit within 7 days or less. Discharge to skilled nursing facilities significantly declined in BPCI hospitals and increased in non-BPCI hospitals. BPCI hospitals were less likely to show an improvement in in-hospital mortality (aOR, 0.67; 95% CI, 0.51-0.86; p = 0.002) or their hospital-level risk-adjusted 30-day or 90-day all-cause readmission rate and 30-day or 90-day all-cause mortality rate.


Hospitals participating in the BPCI program did not have an improvement in process-of-care quality measures nor 30-day or 90-day risk-adjusted all-cause mortality and readmission rates.


Data collected from the GWTG-HF registry and CMS BPCI program did not show that hospitals receiving incentives led to an improvement in the outcomes or cost-savings when managing their HF patients. Although the findings were disappointing, the difference-in-difference approach to collect data may have led to the reporting of certain poor results; for example, both the BPCI and non-BPCI hospitals had an absolute increase in rates of beta-blocker use at discharge, but the increase was less in BPCI hospitals.

Despite limitations, the lack of in-hospital mortality benefit found for Black females causes concern for disparity whether due to a lack of statistical power or true outcomes. In addition, the clinical practice patterns in the early phases of the study compared to current practice with pharmacological and technological advancements may have affected the readmission and all-cause mortality rates, including how individual sites collected patient data.

This study provides clinicians with evidence-based data to consider when managing HF patients that are transitioning between acute to post-acute care. Based on these findings, the BPCI program has been revised to a BPCI Advanced Model to better coordinate care, improve quality of care, and reduce health care costs.

Clinical Topics: Heart Failure and Cardiomyopathies, Acute Heart Failure

Keywords: Heart Failure, Patient Care Team, Quality Improvement

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