Association of Skilled Nursing Facility Participation in a Bundled Payment Model With Institutional Spending for Joint Replacement Surgery
Association of Skilled Nursing Facility Participation in a Bundled Payment Model With Institutional Spending for Joint Replacement Surgery
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DOI：
10.1001/jama.2020.19181
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发表时间：
2020-11-10
影响因子：
120.7
通讯作者：
Epstein, Arnold M.
中科院分区：
文献类型：
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作者：
Barnett, Michael L.;Joynt Maddox, Karen E.;Epstein, Arnold M.
问题 与关节置换手术的捆绑支付模式相关的结果是什么，在这种模式中，熟练护理机构 (SNF) 承担从入院开始的 90 天期间所有护理的财务风险？结果 在对 2013 年至 2017 年接受下肢关节置换术的 80 648 名医疗保险患者进行的双重差分分析中，与对照 SNF 相比，医疗保险捆绑支付护理改善模型 3 与接受捆绑支付的 SNF 患者的平均机构支出 1008 美元（急性后期护理和医院医疗保险允许支付的组合）统计显着下降相关。这意味着基于 SNF 的捆绑支付可能有可能降低下肢关节置换的支出。Importance Medicare 最近完成了一项全国自愿支付示范，即改善护理捆绑支付 (BPCI) 模式 3，其中熟练护理机构 (SNF) 承担患者自 SNF 入院起 90 天内的医疗保险支出责任。几乎没有证据表明与这种新颖的支付模式相关的结果。目的 评估 BPCI 模型 3 与接受下肢关节置换术 (LEJR) 的 Medicare 受益人的支出、医疗保健利用率和患者结果之间的关联。设计、设置和参与者 使用 2013-2017 年医疗保险索赔进行观察性双重差分分析，以评估 BPCI 模型 3 与接受 LEJR 的 80 648 名患者的结果之间的关联。预干预期为 2013 年 1 月至 2013 年 9 月，即第一个 BPCI 队列入组前 9 个月。每个 SNF 的干预后期限从 BPCI 入组后 3 个月延长至 2017 年 12 月。使用 2013 年 SNF 特征的倾向评分匹配，将 BPCI SNF 与对照 SNF 进行匹配。暴露 BPCI 模型 3 参与 SNF 的准入。主要成果和措施 主要成果是机构支出，包括急性后期护理和医院医疗保险允许的付款。其他结果包括其他类别的支出、病例组合的变化、入院数量、家庭健康使用、住院时间以及 SNF 入院 90 天内的医院使用。结果 16 837 名患者（平均 [SD] 年龄，77.5 [9.4] 岁；12 173 [72.3%] 女性）中有 448 个 BPCI SNF，共 18 870 次 LEJR 发作，与 63 811 名患者（平均 [SD] 年龄，77.6 岁）中的 1958 个对照 SNF 相匹配，共 72 005 次 LEJR 发作。 [9.4] 年；46 072 [72.2%] 女性）在干预前和干预后阶段。 79% 的匹配 BPCI SNF 是营利性设施，85% 位于城市地区，85% 是较大企业链的一部分。项目期间，参与 BPCI 的 SNF 和对照之间的患者病例组合或发作量没有系统性变化。 BPCI SNF 的机构支出从 17 956 美元减少到 15 746 美元，匹配对照从 17 765 美元减少到 16 563 美元，差异减少 5.6%（-$1008 [95% CI，-$1603 到 -$414]；P < .001）。这种减少与每个受益人的 SNF 天数减少有关（BPCI SNF 从 26.2 天减少到 21.3 天，匹配对照从 26.3 天减少到 23.4 天；差异变化，-2.0 天 [95% CI，-2.9 到 -1.1]）。死亡率或 90 天再入院率没有显着变化。结论和相关性 在 2013 年至 2017 年接受下肢关节置换术的 Medicare 患者中，BPCI 模型 3 与入院 SNF 引发的平均机构支出下降显着相关。需要进一步的研究来评估其他临床环境中的捆绑支付。本研究比较了参与和不参与 Medicare 捆绑支付计划的熟练护理机构 (SNF) 进行下肢关节置换后 Medicare 受益人在该计划实施之前和之后的机构支出平均水平。
Question What are the outcomes associated with bundled payment models for joint replacement surgery, in which skilled nursing facilities (SNFs) bear financial risk for all care across a 90-day episode beginning with facility admission? Findings In this difference-in-difference analysis of 80 648 Medicare patients undergoing lower extremity joint replacement from 2013-2017, the Medicare Bundled Payments for Care Improvement model 3 was associated with a statistically significant decrease in mean institutional spending of $1008 (a combination of postacute care and hospital Medicare-allowed payments) on patients of SNFs receiving bundled payment compared with control SNFs. Meaning SNF-based bundled payments may have the potential to lower spending for lower extremity joint replacement.Importance Medicare recently concluded a national voluntary payment demonstration, Bundled Payments for Care Improvement (BPCI) model 3, in which skilled nursing facilities (SNFs) assumed accountability for patients' Medicare spending for 90 days from initial SNF admission. There is little evidence on outcomes associated with this novel payment model. Objective To evaluate the association of BPCI model 3 with spending, health care utilization, and patient outcomes for Medicare beneficiaries undergoing lower extremity joint replacement (LEJR). Design, Setting, and Participants Observational difference-in-difference analysis using Medicare claims from 2013-2017 to evaluate the association of BPCI model 3 with outcomes for 80 648 patients undergoing LEJR. The preintervention period was from January 2013 through September 2013, which was 9 months prior to enrollment of the first BPCI cohort. The postintervention period extended from 3 months post-BPCI enrollment for each SNF through December 2017. BPCI SNFs were matched with control SNFs using propensity score matching on 2013 SNF characteristics. Exposures Admission to a BPCI model 3-participating SNF. Main Outcomes and Measures The primary outcome was institutional spending, a combination of postacute care and hospital Medicare-allowed payments. Additional outcomes included other categories of spending, changes in case mix, admission volume, home health use, length of stay, and hospital use within 90 days of SNF admission. Results There were 448 BPCI SNFs with 18 870 LEJR episodes among 16 837 patients (mean [SD] age, 77.5 [9.4] years; 12 173 [72.3%] women) matched with 1958 control SNFs with 72 005 LEJR episodes among 63 811 patients (mean [SD] age, 77.6 [9.4] years; 46 072 [72.2%] women) in the preintervention and postintervention periods. Seventy-nine percent of matched BPCI SNFs were for-profit facilities, 85% were located in an urban area, and 85% were part of a larger corporate chain. There were no systematic changes in patient case mix or episode volume between BPCI-participating SNFs and controls during the program. Institutional spending decreased from $17 956 to $15 746 in BPCI SNFs and from $17 765 to $16 563 in matched controls, a differential decrease of 5.6% (-$1008 [95% CI, -$1603 to -$414]; P < .001). This decrease was related to a decline in SNF days per beneficiary (from 26.2 to 21.3 days in BPCI SNFs and from 26.3 to 23.4 days in matched controls; differential change, -2.0 days [95% CI, -2.9 to -1.1]). There was no significant change in mortality or 90-day readmissions. Conclusions and Relevance Among Medicare patients undergoing lower extremity joint replacement from 2013-2017, the BPCI model 3 was significantly associated with a decrease in mean institutional spending on episodes initiated by admission to SNFs. Further research is needed to assess bundled payments in other clinical contexts.This study compares mean levels of institutional spending for Medicare beneficiaries after lower extremity joint replacement at skilled nursing facilities (SNFs) participating vs not participating in Medicare's bundled payment program, before vs after implementation of the program.