To bundle or not to bundle: A scoping review of the introduction of bundled payments in healthcare

Abstract

Objectives: To explore the key characteristics of bundled payments (BP) implemented in different countries, the challenges and opportunities associated with their adoption, and the potential effects in terms of improved value for different stakeholders. Design: Scoping review. Methods: Literature search on PubMed, Cochrane Library and Web of Science between 01/01/2009 and 10/10/2019, including grey literature and snowballing of references. Results were charted using a standardized form and summarized through direct content analysis using a framework proposed by the OECD. No quality appraisal of the literature was performed, yet to improve trustworthiness several processes were conducted independently by the authors and ultimately compared. A consultation exercise with key experts from the field was not performed. Results: A total of 113 articles were included in the analysis, comprising 22 BP initiatives. Evidence on BP is mainly in the USA (77%), and in the area of orthopaedics (55%), cardiology (46%) and oncology (32%). These usually covered a cycle of care of 90 days (37%) or above (37%). Inpatient and outpatient care were included for 32% of BP and 46% also covered for readmissions, complications and/or emergency department visits. The context in which implementation occurred involved the participation of a multidisciplinary team (73%), standardization of clinical pathways (68%), standardization and monitoring of metrics (55%) and changes to IT systems (32%). Effects in terms of quality were mixed (improvement/no improvement), whereas cost decrease was evident for most BP (63%). Nonetheless, quality or cost effects of BP introduction were not addressed in a third and a quarter of the BP, respectively. Evidence did not confirm negative consequences of BP introduction (e.g. cherry-picking). Conclusion: Evidence for bundled payments seems promising, yet further studies are needed specially as their adoption scales-up for non-surgical episodes of care.