• Aidan P Crowley, Sarah Neville, Chuxuan Sun, Qian Erin Huang, Deborah Cousins, Torrey Shirk, Jingsan Zhu, Austin Kilaru, Joshua M Liao, and Amol S Navathe.
• Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. aidan.crowley@pennmedicine.upenn.edu.
• J Gen Intern Med. 2024 May 1; 39 (7): 118011871180-1187.

BackgroundMedicare's voluntary bundled payment programs have demonstrated generally favorable results. However, it remains unknown whether uneven hospital participation in these programs in communities with greater shares of minorities and patients of low socioeconomic status results in disparate access to practice redesign innovations.ObjectiveExamine whether communities with higher proportions of marginalized individuals were less likely to be served by a hospital participating in Bundled Payments for Care Improvement Advanced (BPCI-Advanced).DesignCross-sectional study using ordinary least squares regression controlling for patient and community factors.ParticipantsMedicare fee-for-service patients enrolled from 2015-2017 (pre-BPCI-Advanced) and residing in 2,058 local communities nationwide defined by Hospital Service Areas (HSAs). Each community's share of marginalized patients was calculated separately for each of the share of beneficiaries of Black race, Hispanic ethnicity, or dual eligibility for Medicare and Medicaid.Main MeasuresDichotomous variable indicating whether a given community had at least one hospital that ever participated in BPCI-Advanced from 2018-2022.Key ResultsCommunities with higher shares of dual-eligible individuals were less likely to be served by a hospital participating in BPCI-Advanced than communities with the lowest quartile of dual-eligible individuals (Q4: -15.1 percentage points [pp] lower than Q1, 95% CI: -21.0 to -9.1, p < 0.001). There was no consistent significant relationship between community proportion of Black beneficiaries and likelihood of having a hospital participating in BPCI-Advanced. Communities with higher shares of Hispanic beneficiaries were more likely to have a hospital participating in BPCI-Advanced than those in the lowest quartile (Q4: 19.2 pp higher than Q1, 95% CI: 13.4 to 24.9, p < 0.001).ConclusionsCommunities with greater shares of dual-eligible beneficiaries, but not racial or ethnic minorities, were less likely to be served by a hospital participating in BPCI-Advanced Policymakers should consider approaches to incentivize more socioeconomically uniform participation in voluntary bundled payments.© 2024. The Author(s), under exclusive licence to Society of General Internal Medicine.

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