The Impact of Bundled Payments for Cardiopulmonary Disease on High-Risk Populations

摘要 我们的医疗保健系统支离破碎，这导致高危人群的结果不太理想 慢性疾病，如心肺疾病，与复杂的医疗或社会需求相结合。 捆绑支付是一种替代支付模式(APM)，可提高控股提供商的效率 对整个护理过程中的成本和质量负责。医疗保险和医疗补助中心 创新(CMMI)在2013年推出了捆绑支付改善护理(BPCI)计划；一个新的 该程序的版本BPCI-Advanced(BPCI-A)将于2018年10月取代BPCI。在这两项下，参与者 达到成本目标的人保留节省的资金，而未能做到这一点的人则支付联邦医疗保险的差额。Bpci- A增加了财政激励措施，并增加了质量措施，以进一步激励改进。 捆绑支付为提供者提供了更好地协调服务和重新设计护理的强大激励， 这可能对医学或社会高危老年人非常有帮助。对于这些人来说 临床创新是迫切需要的，知道哪些正在试验并似乎有效，可能会 对提高护理质量有很大帮助。另一方面，捆绑支付可能会诱使提供商 避免这些患者或在护理上吝啬，这可能会导致不良结果。我们最重要的假设是 BPCI中的经济激励措施对高危心肺患者产生了不利后果，而 加强激励措施和使用BPCI-A中的质量措施将减少其中一些后果。 量化BPCI-A对高危人群的影响至关重要，因为医疗保险和其他支付者 越来越多地转向这些和其他替代支付模式。检查各种医疗和 外科心肺疾病代表了一系列敏锐度和复杂性，我们的目标是1)使用 索赔数据，确定BPCI和BPCI-A如何影响以下方面的心肺支出、获取和结果 医疗和社会高危人群；2)利用国家调查，确定参与 BPCI-A和护理重新设计的关键方法；以及3)结合索赔和调查数据，确定患者， 在BPCI-A下，医院、市场和战略预测因素的成功。 我们拟议的工作将提供及时的信息，为BPCI-A的年度更新提供信息，并确定临床 干预措施是改善所有患者心肺护理的有力候选者。这样的工作可能会有所帮助 保护和优化高危人群的结果。如果没有这些发现和由此产生的政策 根据这些建议，BPCI-A可能会产生意想不到的不良后果。

Abstract Our health care system is fragmented, which leads to suboptimal outcomes for high-risk populations with chronic conditions, such as cardiopulmonary disease, combined with complex medical or social needs. Bundled payments are an alternative payment model (APM) that incents efficiency by holding providers accountable for costs and quality across an entire episode of care. The Center for Medicare and Medicaid Innovation (CMMI) launched the Bundled Payments for Care Improvement (BPCI) initiative in 2013; a new version of this program, BPCI-Advanced (BPCI-A), replaces BPCI in October 2018. Under both, participants that meet cost targets keep the savings, while those that fail to do so pay Medicare back the difference. BPCI- A has increased the financial incentives and added quality measures to further incentivize improvements. Bundled payments provide strong incentives for providers to better-coordinate services and redesign care, which could be very helpful for medically or socially high-risk older adults. These are populations for which clinical innovations are sorely needed, and knowing which ones are being tried and appear to be working could be very helpful in improving quality of care. On the other hand, bundled payments could induce providers to avoid those patients or skimp on care, which could result in poor outcomes. Our overarching hypothesis is that the financial incentives in BPCI had adverse consequences in high-risk cardiopulmonary patients, while the enhanced incentives and use of quality measures in BPCI-A will reduce some of those consequences. Quantifying the impact of BPCI-A on high-risk populations is critically important as Medicare and other payers increasingly shift towards these and other alternative payment models. Examining a variety of medical and surgical cardiopulmonary conditions that represent a range of acuity and complexity, our aims are to 1) Using claims data, determine how BPCI and BPCI-A impact cardiopulmonary spending, access, and outcomes for medically and socially high-risk populations; 2) Using a national survey, identify predictors of participation in BPCI-A, and key approaches to care redesign; and 3) Combining claims and survey data, determine patient, hospital, market, and strategic predictors of success under BPCI-A. Our proposed work will provide timely information to inform annual updates to BPCI-A, and identify clinical interventions that are strong candidates to improve cardiopulmonary care for all patients. Such work could help to protect and optimize outcomes among high-risk populations. Absent these findings and the resulting policy recommendations, BPCI-A could have unintended adverse consequences.