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

由于医疗保险支出的增长和急性期后护理效果的不确定性， 在替代设置下提供（例如，住院康复设施，专业护理设施，家庭保健 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，情节- 为接受选择性关节置换术的患者实施基于前瞻性捆绑支付模式 作为其2016年关节置换综合护理（CJR）规则的一部分。捆绑包基于住院患者 DRGs，包括一段护理期间的所有相关医疗保险费用，定义为住院时间和90 无论急性后护理环境如何，急性后出院天数。在这个应用程序中，我们利用 自然实验提供了CMS的区域变化，在执行CJR规则，以检查 捆绑对约40万名医疗保险人员的服务使用、结果和护理成本的影响 每年进行关节置换的受益人。具体来说，我们的目标是：1。检验…的影响 捆绑急性护理住院时间、急性护理后出院设置和90天医疗护理费用 在接受全膝关节（TKA）或髋关节（THA）置换术的受益人中， 付款; 2.估计捆绑治疗对急性期后12个月临床和使用结局的影响 护理出院的目标条件的患者，并量化潜在的溢出效应的护理和 非靶向肌肉骨骼（髋部骨折、截肢）和神经系统（卒中）患者的结局 条件; 3。估计捆绑销售对向目标患者提供的护理价值的影响， 和非针对性的条件，并讨论这些关系对急性后护理政策的影响 方案倡议。使用差分中差分技术，我们将估计 捆绑12个月的结果，包括并发症、医疗（不）稳定性、再次住院和 mortality.对非靶向疾病患者的系列队列进行的分析将提供额外的 比较组，使我们能够估计可能的溢出效应的CJR规则。结果从这个 这项研究将为所有对提供有效的 为需要康复的大量和不断增加的老年人提供急症后护理，包括 政府、决策者、支付者和消费者。调查结果也将在目前的ACA相关- 取代和废除环境，预计将进一步减少获得和偿还这些 以及其他急症后护理服务。

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.