OBJECTIVES : Bundled payments (BP) are increasingly adopted to steer healthcare systems towards value. Through prospective payments that in principle cover all care related to conditions, BP shifts financial and clinical accountability of care to providers. Because spending at the condition-level is variable and dependent on the disease burden concerning the patient population, risk adjustment is required to prevent unintended effects. We aim to provide insight into whether and how burden of disease is incorporated in current BP initiatives.

METHODS : A systematic review was conducted including titles up to November 2020, following PRISMA guidelines. PubMed/Medline, Embase, Web of Science, Cochrane, CINAHL, ProQuest and Google Scholar were searched. To be included, articles had to report on an established BP initiative implemented in an OECD country, with reference to burden of disease in relation to the BP design.

RESULTS : A total of 39 articles were included of which 82% were published after 2015. Most BPs were implemented in the United States, with more than half of articles discussing the Bundled Payment for Care Improvement initiative. Total joint arthroplasty was the targeted condition in 47% of the articles. We identified three ‘levels’ of burden of disease corrections, level 1: socio-demographic characteristics, level 2: disease specific characteristics and level 3: co-morbidities.

CONCLUSIONS : Burden of disease is increasingly adjusted for in BPs, yet in limited form (predominantly on socio-demographic characteristics). Given substantial evidence for the relevance of burden of disease for variation in spending, adequately accounting for burden of disease in BP design is required to increase provider participation, maximize value and limit potential adverse effects.