Safety-Net Hospitals Under Mandatory Bundled Payment

项目总结/摘要 安全网医院（SNH）在美国医疗保健系统中发挥着重要作用， 照顾低收入、医疗弱势群体。许多观察家认为，由于 由于其相对较弱的财务状况，SNH在价值基础上受到了不公平的惩罚， purchasing.这让SNH感到不安，因为医疗保险和医疗补助服务中心 (CMS)积极追求将医疗保险支付的更大部分与价值挂钩的目标 通过替代支付机制。 捆绑支付是当前基于价值的支付方案中的一种重要模式。的 Medicare Bundled Payments for Care Improvement Initiative（BPCI），于2013年实施， 迄今为止，已促使约500家医院自愿参与。 2016年4月，CMS推出了关节置换综合护理（CJR）模式， 全髋关节置换术和全膝关节置换术。与BPCI不同，CJR是强制性的 对于位于指定MSA的所有非豁免医院，通过随机化选择。因此 分析CJR提供了一个独特的研究机会，因为比较CJR医院 与其他医院进行比较，避免了由于与以下因素相关的不可观察的选择效应而导致的混淆： 自愿参与。 CMS正在监督对CJR的外部评估。重点是节省医疗保险 程序，同时坚持质量标准和比较之间的CJR和控制 集团医院虽然支出控制是该计划的主要目的，但对 SNH具有重要意义。然而，评估并没有考虑到独特的 SNH面临的挑战本项目将通过研究民事司法制度改革对以下方面的影响， SNH相对于其他CJR医院，特别关注前五年的改进 多年的节目。使用描述和统计技术，我们的目标是1）测量 在CJR下，通过关注SNH状态的医院特征改善绩效; 2） 确定患者/人群与医院特征对 在民事司法改革下改善驾驶表现。更好地了解哪些类型的医院 以及哪些人群在CJR下取得了最大的成功，哪些人群未能取得成功， 在CMS考虑未来替代付款时，改进性能将是有价值的 机制等

PROJECT SUMMARY/ABSTRACT Safety-net hospitals (SNHs) play an essential role in the U.S. health care system by providing care for low income, medically vulnerable populations. Many observers believe that because of their relatively weaker financial position, SNHs have been unfairly penalized under value-based purchasing. This is unsettling for SNHs, as the Centers for Medicare and Medicaid Services (CMS) actively pursues the goal of tying a greater portion of Medicare payments to value through alternative payment mechanisms. Bundled payment is an important model among current value-based payment programs. The Medicare Bundled Payments for Care Improvement Initiative (BPCI), implemented in 2013 for a defined set of conditions, has prompted voluntary participation by about 500 hospitals to date. In April 2016, CMS launched the Comprehensive Care for Joint Replacement (CJR) model for total hip replacement and total knee replacement surgery. Unlike the BPCI, CJR is mandatory for all non-exempt hospitals located in designated MSAs, selected by randomization. Hence analyzing CJR presents a unique opportunity for research because comparing CJR hospitals with other hospitals avoids confounding due to unobservable selection effects associated with voluntary participation. CMS is overseeing an external evaluation of the CJR. Focus is on savings to the Medicare program while upholding quality standards and comparisons are between CJR and control group hospitals. While spending control is the primary purpose of the program, impacts on SNHs are of significant consequence. Yet the evaluation does not consider the unique challenges facing SNHs. This project will address this gap by examining the impact of CJR on SNHs relative to other CJR hospitals by focusing in particular on improvement over the first five years of the program. Using descriptive and statistical techniques our aims are 1) to measure performance improvement under CJR by hospital characteristics focusing on SNH status and 2) to determine the relative contribution of patient/population versus hospital characteristics to driving performance improvement under CJR. Better understanding of what types of hospitals and which populations are achieving the greatest success under CJR and where it has failed to improve performance will be valuable to CMS as it considers future alternative payment mechanisms.