Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients.
Association of Mandatory Bundled Payments for Joint Replacement With Postacute Care Outcomes Among Medicare and Medicaid Dual Eligible Patients.
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Medicare和Medicaid双重合格患者之间的强制性捆绑付款协会与急性护理后的关节替代付款协会。
DOI：
10.1097/mlr.0000000000001473
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发表时间：
2021-02-01
期刊：
影响因子：
3
通讯作者：
Thirukumaran CP
中科院分区：
文献类型：
--
作者：
Li Y;Ying M;Cai X;Thirukumaran CP
医疗保险关节置换综合护理（CJR）模式是一项强制性捆绑支付计划，于2016年4月开始实施，适用于随机选择的大都市统计区（msa）的医院，可能有助于减少急性后护理（PAC）的使用和发作成本，但其对医疗补助和非医疗补助受益人之间差异的影响尚不清楚。确定CJR计划对医疗补助-医疗补助双重资格的PAC使用差异和结果的影响。2013 - 2017年的观察性队列研究，基于对医疗保险数据的差异中差（DID）分析，对在75家CJR msa和121家对照msa医院接受髋关节或膝关节手术的1,239,452名医疗保险患者、57,452名享受全额医疗补助的双重资格患者和50,189名享受部分医疗补助的双重资格患者进行了研究。机构PAC（熟练护理设施[SNF]、住院康复或长期医院护理）使用率和再入院率的风险调整差异；对于出院到SNF的患者亚组，风险调整后的SNF住院时间、支付和质量（由星级评定衡量）、成功出院到社区的比率以及过渡到长期住院的养老院居民的比率的差异。CJR项目与所有三组患者机构PAC使用和再入院减少有关。例如，仅医疗保险患者的90天再入院率降低了1.8个百分点（DID-estimate= - 1.8, 95%可信区间[CI] - 2.6至- 0.9,p<0.001），完全获益双入选患者的90天再入院率降低了1.6个百分点（DID-estimate= - 1.6, 95% CI - 3.1至- 0.1,p=0.04），部分获益双入选患者的90天再入院率降低了2.0个百分点（DID-estimate= - 2.0, 95% CI - 3.6至- 0.4,p=0.01）。这些与cjr相关的效应在双重符合条件的患者和仅参加医疗保险的患者之间没有差异（对于完全受益的患者，上述did估计值的差异=0.2,95% CI为- 1.4至1.7,p=0.81；对于部分受益的患者，差异为- 0.3,95% CI为- 1.9至1.3,p=0.74）。在SNF出院的患者中，CJR项目对成功的社区出院、过渡到长期护理或他们的持续差异没有影响。CJR计划并没有帮助减少与医疗-医疗补助双重资格相关的再入院或SNF特定结果的持续差异，可能是由于缺乏减少差异和改善SNF结果的财政激励。
The Medicare Comprehensive Care for Joint Replacement (CJR) model, a mandatory bundled-payment program started in April 2016 for hospitals in randomly selected Metropolitan Statistical Areas (MSAs), may help reduce post-acute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown. To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status. Observational cohort study of 2013–17, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs. Risk-adjusted differences in rates of institutional PAC (skilled nursing facility [SNF], inpatient rehabilitation, or long-term hospital care) use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident. The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage-point (DID-estimate=−1.8, 95% confidence interval [CI] −2.6 to −0.9, p<0.001) for Medicare-only patients, by 1.6 percentage points (DID-estimate=−1.6, 95% CI −3.1 to −0.1, p=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID-estimate=−2.0, 95% CI −3.6 to −0.4, p=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID-estimates=0.2, 95% CI −1.4 to 1.7, p=0.81 for full-benefit patients; and −0.3, 95% CI −1.9 to 1.3, p=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities. The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.