Influence of Participation in the BPCI-A Initiative on 30-Day Heart Failure Unplanned Readmission Rates Among U.S. Hospitals

Abstract

Background: The Bundled Payments for Care Improvement Advanced (BPCI-A) initiative incentivize participating hospitals if they achieved less than the target spending amount for the selected condition and penalizes them if they exceeded the target. The BPCI-A program aims to enhance care quality and reduce spending. One of the quality measures targeted by BPCI-A is hospital readmissions. Heart failure is one of the leading causes of hospital readmission effectiveness of BPCI-A in reducing cardiac-related readmissions, particularly for heart failure, and the influence of hospital characteristics on program outcomes remain uncertain. This series of studies comprehensively evaluated the impact of BPCI-A on heart failure readmission rates.

Methods: First, a scoping review was conducted to synthesize the existing literature on hospital characteristics, BPCI-A participation, and associated readmission outcomes, specifically focusing on cardiac care. Subsequently, a second study utilizing a propensity score matching (PSM) with national hospital-level datasets compared the baseline characteristics and readmission outcomes between hospitals participating in the program and a matched group of their counterparts that never participated in the program. Lastly, a retrospective matched-cohort study was conducted to validate the findings from the second study by evaluating whether participation in the BPCI-A program influenced 30-day heart failure readmissions, including subgroup analyses by hospital size, ownership, and teaching status, using weighted regression modeling and interaction analyses.

Results: The scoping review revealed limited effectiveness of BPCI-A in reducing cardiac-related readmissions broadly, emphasizing existing disparities among hospitals. Empirical findings from Journal Article 2 demonstrated significant baseline differences: BPCI-A hospitals were larger, urban, teaching-oriented, and for-profit institutions. Post-matching analyses indicated a modest but significant association between BPCI-A participation and reduced heart failure readmissions (4.1 percentage points lower, p<0.001). Confirmatory analyses from Journal Article 3 validated these results, showing a 4.2 percentage-point reduction in readmissions associated with participation, with substantial heterogeneity by hospital characteristics. Small, public, and non-teaching hospitals benefited disproportionately from participation.

Conclusion: Participation in BPCI-A is modestly associated with lower heart failure readmission rates, especially among hospitals historically disadvantaged by resource constraints. However, BPCI-A alone appears insufficient to eliminate persistent disparities or achieve substantial reductions universally. Future bundled payment policies must be tailored to hospital contexts, address under-resourced institutions by providing targeted support to enhance equity and effectiveness in reducing heart failure readmissions.