Evaluating the Effects of CMS' Prospective Episode-Based "Bundling" Payment Model for Lower Limb Joint Replacement: Post-acute Care Setting, Costs and Patient Outcomes

由医疗保险支出的增长和对急性后护理有效性的不确定性推动 在替代环境中提供(例如，住院康复设施、熟练护理设施、家庭健康 机构)，医疗保险和医疗补助服务中心(CMS)已经建立了一个强制性的，插曲- 为接受选择性关节成形术的人实施基于预期的捆绑支付模式 作为其2016年关节置换(CJR)全面护理规则的一部分。套餐以住院患者为基础 DRGs和包括护理期间的所有相关医疗保险费用，定义为住院天数和90% 急性出院后天数，与急性后护理环境无关。在此应用程序中，我们利用 CMS在执行CJR规则时的地区差异提供的自然实验 捆绑对大约400,000个联邦医疗保险的服务使用、结果和护理成本的影响 每年接受联合替换的受益人。具体地说，我们的目标是：1.检查 捆绑急性护理住院时间、急性护理出院设置和90天医疗费用 在接受全膝关节置换术(TKA)或髋关节置换术(THA)的受益人中， 2.评估急性发作后12个月捆绑对临床和使用结果的影响 有针对性的疾病患者的护理出院，并量化潜在的溢出效应对护理和 非靶向肌肉骨骼(髋部骨折、截肢)和神经系统(中风)患者的预后 条件；以及3.评估捆绑对向有针对性的患者提供的护理价值的影响 和非靶向疾病，并讨论这些关系对急性后护理政策的影响 和计划倡议。使用差分差分技术，我们将估计 捆绑12个月的结果，包括并发症、医疗(In)稳定性、再次住院和 死亡率。与非靶向疾病患者的系列队列进行的分析将提供额外的 并使我们能够估计CJR规则可能产生的溢出效应。由此产生的结果 研究将为所有对提供有效信息的挑战感兴趣的人提供重要的实时信息 向需要康复的大量和越来越多的老年人提供急诊后护理，包括 政府、政策制定者、支付者和消费者。这些发现也将与当前的ACA相关- 取代和废除环境，预计这将进一步减少获得这些服务的机会和报销 以及其他急性后护理服务。

Prompted by the growth in Medicare spending and uncertainty about the effectiveness of post-acute care provided at alternative settings (e.g., inpatient rehabilitation facilities, skilled nursing facilities, home health agencies), the Center for Medicare and Medicaid Services (CMS) has established a mandatory, episode- based, prospective bundling payment model for persons undergoing elective joint arthroplasties, implemented as part of its Comprehensive Care for Joint Replacement (CJR) Rule of 2016. Bundles are based on inpatient DRGs and include all relevant Medicare costs during an episode-of-care, defined as the inpatient stay and 90 days post-acute discharge, regardless of post-acute care setting. In this application, we take advantage of the natural experiment afforded by CMS’ regional variation in implementation of the CJR Rule to examine the impact of bundling on service use, outcomes, and cost of care for the approximately 400,000 Medicare beneficiaries undergoing joint replacements every year. Specifically, our aims are: 1. To examine the effect of bundling on acute care length-of-stay, post-acute care discharge setting, and 90-day medical care costs among beneficiaries undergoing total knee (TKA) or hip (THA) arthroplasty, conditions targeted for bundled payments; 2. To estimate the effect of bundling on clinical and utilization outcomes at 12-months post-acute care discharge among patients with targeted conditions, and to quantify potential spillover effects on care and outcomes of patients with non-targeted musculoskeletal (hip fractures, amputations) and neurological (stroke) conditions; and 3. To estimate the impact of bundling on the value of care provided to patients with targeted and non-targeted conditions, and to discuss the implications of these relationships for post-acute care policy and program initiatives. Using difference-in-difference-in-difference techniques, we will estimate the effect of bundling on 12-month outcomes, including complications, medical (in)stability, re-hospitalizations, and mortality. Analyses conducted with serial cohorts of patients with non-targeted conditions will provide additional comparison groups and enable us to estimate possible spillover effects of the CJR Rule. Results from this study will provide important “real time” information for all interested in the challenges of providing effective post-acute care to the large and growing number of elderly persons requiring rehabilitation, including government, policy-makers, payers, and consumers. The findings will also be relevant in the current ACA- replace and repeal environment, which is expected to further reduce access to and reimbursement for these and other post-acute care services.