# Safety-Net Hospitals Under Mandatory Bundled Payment

> **NIH AHRQ R03** · BOSTON UNIVERSITY MEDICAL CAMPUS · 2021 · $99,990

## Abstract

PROJECT SUMMARY/ABSTRACT
Safety-net hospitals (SNHs) play an essential role in the U.S. health care system by providing
care for low income, medically vulnerable populations. Many observers believe that because of
their relatively weaker financial position, SNHs have been unfairly penalized under value-based
purchasing. This is unsettling for SNHs, as the Centers for Medicare and Medicaid Services
(CMS) actively pursues the goal of tying a greater portion of Medicare payments to value
through alternative payment mechanisms.
Bundled payment is an important model among current value-based payment programs. The
Medicare Bundled Payments for Care Improvement Initiative (BPCI), implemented in 2013 for a
defined set of conditions, has prompted voluntary participation by about 500 hospitals to date.
In April 2016, CMS launched the Comprehensive Care for Joint Replacement (CJR) model for
total hip replacement and total knee replacement surgery. Unlike the BPCI, CJR is mandatory
for all non-exempt hospitals located in designated MSAs, selected by randomization. Hence
analyzing CJR presents a unique opportunity for research because comparing CJR hospitals
with other hospitals avoids confounding due to unobservable selection effects associated with
voluntary participation.
CMS is overseeing an external evaluation of the CJR. Focus is on savings to the Medicare
program while upholding quality standards and comparisons are between CJR and control
group hospitals. While spending control is the primary purpose of the program, impacts on
SNHs are of significant consequence. Yet the evaluation does not consider the unique
challenges facing SNHs. This project will address this gap by examining the impact of CJR on
SNHs relative to other CJR hospitals by focusing in particular on improvement over the first five
years of the program. Using descriptive and statistical techniques our aims are 1) to measure
performance improvement under CJR by hospital characteristics focusing on SNH status and 2)
to determine the relative contribution of patient/population versus hospital characteristics to
driving performance improvement under CJR. Better understanding of what types of hospitals
and which populations are achieving the greatest success under CJR and where it has failed to
improve performance will be valuable to CMS as it considers future alternative payment
mechanisms.

## Key facts

- **NIH application ID:** 10296964
- **Project number:** 1R03HS027786-01A1
- **Recipient organization:** BOSTON UNIVERSITY MEDICAL CAMPUS
- **Principal Investigator:** Kathleen Carey
- **Activity code:** R03 (R01, R21, SBIR, etc.)
- **Funding institute:** AHRQ
- **Fiscal year:** 2021
- **Award amount:** $99,990
- **Award type:** 1
- **Project period:** 2021-07-01 → 2022-06-30

## Primary source

NIH RePORTER: https://reporter.nih.gov/project-details/10296964

## Citation

> US National Institutes of Health, RePORTER application 10296964, Safety-Net Hospitals Under Mandatory Bundled Payment (1R03HS027786-01A1). Retrieved via AI Analytics 2026-05-26 from https://api.ai-analytics.org/grant/nih/10296964. Licensed CC0.

---

*[NIH grants dataset](/datasets/nih-grants) · CC0 1.0*