Cost of Joint Replacement Using Bundled Payment Models
Cost of Joint Replacement Using Bundled Payment Models
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DOI：
10.1001/jamainternmed.2016.8263
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发表时间：
2017-02-01
影响因子：
39
通讯作者：
Emanuel, Ezekiel J.
中科院分区：
文献类型：
--
作者：
Navathe, Amol S.;Troxel, Andrea B.;Emanuel, Ezekiel J.
重要信息医疗保险在67个城市地区为大约800家医院推出了强制性的关节置换综合护理捆绑支付模式，这是根据其在自愿急性护理Epilepsy（ACE）和护理改善捆绑支付（BPCI）示范项目中的经验。ACE和BPCI的信息很少，无法指导医院重新设计强制性关节置换bundle.ObjectiveTo分析下肢关节置换捆绑支付事件（包括住院和30天的PAC）的质量、内部医院成本和急性期后护理（PAC）支出的变化。这项观察性研究随访了3942名在浸信会卫生系统（BHS）接受下肢关节置换术的患者，参与ACE和BPCI的患者。暴露BHS捆绑支付下的下肢关节置换手术。主要结果和测量平均每次发作的医疗保险支付，再入院，急诊科就诊，延长住院时间，结果：总的来说，观察到3942例来自BHS的患者（平均[SD]年龄，72.4 [8.4]岁）。在2008年7月至2015年6月期间，平均医疗保险支出下降了20.8%，从26785美元下降到21208美元（P < .001），3738次关节置换没有并发症。204例关节置换术并发症的费用从38537美元下降到33216美元（P = 0.61），下降了13.8%。再入院率和急诊就诊率分别下降了1.4%（P = 0.14）和0.9%（P = 0.98），而住院时间延长的事件减少了67.0%（P <0.001）。患者疾病严重程度保持稳定。到2015年，51.2%的医院整体节省来自内部成本削减，48.8%来自PAC支出削减。植入成本的降低，平均每例降低1920.68美元（29%），占医院节省费用的最大比例。平均PAC支出下降$2443.12（27%）每例，主要是从减少住院康复和熟练的护理设施的支出，但只有当捆绑包括财政责任PAC.CONCLUSIONS和相关性在一段时间内，医疗保险支付关节置换事件增加了5%，捆绑支付程序在BHS与大量的医院储蓄和医疗保险支付减少。只有当PAC被纳入捆绑包时，PAC支出才会减少。
IMPORTANCE Medicare launched the mandatory Comprehensive Care for Joint Replacement bundled payment model in 67 urban areas for approximately 800 hospitals following its experience in the voluntary Acute Care Episodes (ACE) and Bundled Payments for Care Improvement (BPCI) demonstration projects. Little information from ACE and BPCI exists to guide hospitals in redesigning care for mandatory joint replacement bundles.OBJECTIVE To analyze changes in quality, internal hospital costs, and postacute care (PAC) spending for lower extremity joint replacement bundled payment episodes encompassing hospitalization and 30 days of PAC.DESIGN, SETTING, AND PARTICIPANTS This observational study followed 3942 total patients with lower extremity joint replacement at Baptist Health System (BHS), which participated in ACE and BPCI.EXPOSURES Lower extremity joint replacement surgery under bundled payment at BHS.MAIN OUTCOMES AND MEASURES Average Medicare payments per episode, readmissions, emergency department visits, prolonged length of stay, and hospital savings from changes in internal hospital costs and PAC spending.RESULTS Overall, 3942 patients (mean [SD] age, 72.4 [8.4] years) from BHS were observed. Between July 2008 and June 2015, average Medicare episode expenditures declined 20.8%, from $26 785 to $21 208 (P < .001) for 3738 episodes of joint replacement without complications. It declined 13.8% from $38 537 to $33 216 (P = .61) for 204 episodes of joint replacement with complications. Readmissions and emergency department visits declined 1.4%(P = .14) and 0.9%(P = .98), respectively, while episodes with prolonged length of stay decreased 67.0%(P < .001). Patient illness severity remained stable. By 2015, 51.2% of overall hospital savings had come from internal cost reductions and 48.8% from PAC spending reductions. Reductions in implant costs, down on average $1920.68 (29%) per case, contributed the greatest proportion of hospital savings. Average PAC spending declined $2443.12 (27%) per case, largely from reductions in inpatient rehabilitation and skilled nursing facility spending but only when bundles included financial responsibility for PAC.CONCLUSIONS AND RELEVANCE During a period in which Medicare payments for joint replacement episodes increased by 5%, bundled payment for procedures at BHS was associated with substantial hospital savings and reduced Medicare payments. Decreases in PAC spending occurred only when it was included in the bundle.