How Do Bundled Payment Initiatives Account for Differences in Patient Risk Profile? A Systematic Review

• Published in: Value in health 2024-12
• Main Authors: Hendriks, Celine MR, Koster, Fiona, Cattel, Daniëlle, Kok, Marc R., Weel-Koenders, Angelique EAM, Barreto, Deirisa Lopes, Eijkenaar, Frank
• Format: Article
• Language: English
• Subjects: bundled payment; patient exclusion; patient risk profile; risk adjustment; risk stratification
• ISSN: 1098-3015; 1524-4733; 1524-4733
• DOI: 10.1016/j.jval.2024.11.011

Bundled payments (BPs) are increasingly being adopted to enable the delivery of high-value care. For BPs to reach their goals, accounting for differences in patient risk profile (PRP) predictive of spending is crucial. However, insight is lacking into how this is done in practice. This study aims to fill this gap. We conducted a systematic review of literature published until February 2024, focusing on BP initiatives in OECD countries. We collected data on initiatives’ general characteristics, details on the (stated reasons for) approaches used to account for PRP, and suggested improvements. Patterns within and across initiatives were analyzed using extraction tables and thematic analysis. We included 91 documents about 17 initiatives covering various conditions and procedures. Across these initiatives, patient exclusion (n=14) and risk adjustment (n=12) of bundle prices were the most applied methods, while risk stratification was less common (n=3). Most authors stated mitigating perverse incentives as the primary reason for PRP accounting. Commonly used risk factors included comorbidities and sociodemographic and condition/procedure-specific characteristics. Our findings show that, despite increasingly sophisticated approaches over time, key areas for improvement included better alignment with value and equity goals, and enhanced data availability for more comprehensive corrections for relevant risk factors. BP initiatives use various approaches to account for PRP differences. Despite a trend towards more sophisticated approaches, most remain basic with room for improvement. To enable cross-initiative comparisons and learning, it is important that stakeholders involved in BPs be transparent about the (reasons for) design choices made. •While bundled payments can potentially enhance high-value care, effective implementation requires adequate accounting for patient risk profile (PRP). This study provides insight into how bundled payment initiatives achieve this.•Most initiatives primarily use patient exclusion and risk adjustment, with risk stratification being less common. Commonly accounted for risk factors include comorbidities, sociodemographic characteristics and condition/procedure-specific characteristics.•Further improvements of PRP accounting methods are needed to better align with value and equity goals.