Two-Year Evaluation of Mandatory Bundled Payments for Joint Replacement
Two-Year Evaluation of Mandatory Bundled Payments for Joint Replacement
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DOI：
10.1056/nejmsa1809010
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发表时间：
2019-01-17
影响因子：
158.5
通讯作者：
Mehrotra, Ateev
中科院分区：
文献类型：
--
作者：
Barnett, Michael L.;Wilcock, Andrew;Mehrotra, Ateev
2016年，医疗保险实施了关节置换综合护理（CJR），这是随机选择的大都市统计区的髋关节或膝关节置换的国家强制性付费模式。这些地区的医院根据每次髋关节或膝关节置换事件的医疗保险支出（定义为住院加出院后90天）获得奖金或支付罚款。方法我们使用2015年至2017年的医疗保险索赔进行了差异中的差异分析，包括CJR计划中捆绑支付的前2年。我们评估了髋关节或膝关节置换事件在75个大都市统计区随机分配到强制参与CJR程序（支付大都市统计区，以下简称为“治疗”区）相比，在121个控制区，之前和之后的CJR模型的实施。主要结果是每次髋关节或膝关节置换的机构支出（i。例如，医疗保险支付给机构，主要是医院和急性后护理设施），术后并发症的发生率，以及“高风险”患者的百分比（即。例如，患者的花费风险升高--患者选择的一个衡量标准）。分析根据医院和患者特征以及手术进行了调整。从2015年到2017年，治疗区的803家医院进行了280，161例髋关节或膝关节置换手术，对照区的962家医院进行了377，278例手术。CJR模型启动后，治疗区每次关节置换发作的机构支出下降幅度大于对照区（差异变化[即，相对于CJR模型前阶段的变化的组间差异]，-812美元，或相对于治疗组基线的差异降低-3.1%; P
BACKGROUNDIn 2016, Medicare implemented Comprehensive Care for Joint Replacement (CJR), a national mandatory bundled-payment model for hip or knee replacement in randomly selected metropolitan statistical areas. Hospitals in such areas receive bonuses or pay penalties based on Medicare spending per hip- or knee-replacement episode (defined as the hospitalization plus 90 days after discharge).METHODSWe conducted difference-in-differences analyses using Medicare claims from 2015 through 2017, encompassing the first 2 years of bundled payments in the CJR program. We evaluated hip-or knee-replacement episodes in 75 metropolitan statistical areas randomly assigned to mandatory participation in the CJR program (bundledpayment metropolitan statistical areas, hereafter referred to as "treatment" areas) as compared with those in 121 control areas, before and after implementation of the CJR model. The primary outcomes were institutional spending per hip-or knee-replacement episode (i. e., Medicare payments to institutions, primarily to hospitals and post-acute care facilities), rates of postsurgical complications, and the percentage of " high-risk" patients (i. e., patients for whom there was an elevated risk of spending - a measure of patient selection). Analyses were adjusted for the hospital and characteristics of the patients and procedures.RESULTSFrom 2015 through 2017, there were 280,161 hip-or knee-replacement procedures in 803 hospitals in treatment areas and 377,278 procedures in 962 hospitals in control areas. After the initiation of the CJR model, there were greater decreases in institutional spending per joint-replacement episode in treatment areas than in control areas (differential change [i.e., the between-group difference in the change from the period before the CJR model], -$812, or a -3.1% differential decrease relative to the treatment- group baseline; P