Spillover Effects of Comprehensive Care for Joint Replacement (CJR) model

项目摘要 为了在控制成本的同时提高医疗质量，医疗保险正在摆脱传统的按需收费， 服务偿还改为按价值付款。这一转变可能会产生重大影响， 医疗保险人口，如果它导致实践范围的变化，影响所有患者。理解影响 这些溢出效应对更大的卫生保健系统的影响是至关重要的评估联邦政策的影响。 我们建议通过研究医疗保险的一个关键的基于价值的支付， 关节置换综合护理（CJR）计划。 2016年4月，Medicare推出了CJR计划-其第一个强制性捆绑支付计划- 接受髋关节和膝关节置换（也称为下肢关节置换或LEJR）的患者。的 该计划要求医院对LEJR事件（定义为住院时间）的成本和质量负责 出院后90天。CJR计划在67个随机选择的实施 大都市统计区（MSA），允许溢出效应的因果估计。 我们的长期目标是了解医疗保险人群的创新支付模式如何影响 更广泛的医疗保健系统。我们的中心假设是，CJR催化实践范围的变化，因此， 减少整体医疗服务的使用，同时保持医疗保险优势中的护理质量， 有商业保险的LEJR患者。我们还假设，溢出效应的大小减少 当CJR的参与成为自愿的。从2018年1月开始，在最初的67个医疗服务区中， 可以选择继续或退出CJR计划。 这项建议有三个具体目标。首先，我们旨在评估CJR对卫生服务使用的溢出效应 关于LEJR其次，我们的目的是评估CJR对护理质量和支出的溢出效应 关于LEJR第三，我们的目标是评估当参与成为 在最初的67项管理事务协定中，有33项是自愿的。 为了实现这些目标，我们将使用来自卫生保健成本研究所的索赔数据库，其中包括25%的 全国所有医疗保险优势和商业保险参保人，并进行差异化， 差异分析。CJR计划有可能影响医疗服务和医疗保健支出， 患者超出其目标群体。我们的提案将为评估联邦 整体医疗系统的政策。

Project Summary In an effort to improve quality of care while controlling costs, Medicare is moving away from traditional fee-for- service reimbursement to value-based payments. This shift may have significant ramifications beyond the Medicare population if it leads to practice-wide changes that affect all patients. Understanding the implications of these spillover effects on the larger health care system is critical for assessing the impacts of federal policy. We propose to investigate the spillover effects by studying one of Medicare's key value-based payments, the Comprehensive Care for Joint Replacement (CJR) program. In April 2016, Medicare introduced the CJR program – its first mandatory bundled payment program – for its patients undergoing hip and knee replacements (also called lower extremity joint replacements or LEJR). The program holds hospitals accountable for the cost and quality of the LEJR episode, defined as the inpatient stay and 90 days following hospital discharge. The CJR program was implemented in 67 randomly selected metropolitan statistical areas (MSAs), allowing for a causal estimate of spillover effects. Our long-term objective is to understand how innovative payment models for the Medicare population affect the broader health care system. Our central hypothesis is that CJR catalyzes practice-wide changes, therefore reducing overall health service use while maintaining the quality of care among Medicare Advantage and commercially-insured LEJR patients. We also hypothesize that the magnitude of spillover effects decreased when CJR participation became voluntary. Starting in January 2018, hospitals in 33 of the original 67 MSAs had the option to continue with or withdraw from the CJR program. This proposal has three specific aims. First, we aim to assess the spillover effects of CJR on health service use related to LEJR. Second, we aim to assess the spillover effects of CJR on quality of care and expenditures related to LEJR. Third, we aim to assess changes in the spillover effects of CJR when participation became voluntary in 33 of the original 67 MSAs. To accomplish these aims, we will use a claims database from the Health Care Cost Institute that includes 25% of all Medicare Advantage and commercial insurance enrollees in the nation, and conduct difference-in- differences analyses. The CJR program has the potential to affect care delivery and health care spending for patients beyond its target group. Our proposal will provide critical information in assessing the impact of federal policies on the health care system at large.