Comparing the Impact of Voluntary and Mandatory Bundled Payments on Disparities in Surgical Care

项目摘要 本研究探讨如何捆绑支付实施通过自愿和强制参与的影响 脆弱患者的获得和结果-需要向决策者提供关于更广泛的 政策影响以及是否通过自愿和/或强制参与来扩大捆绑支付。为 下肢关节置换术（LEJR）的最大支付者，这是美国增长最快的择期手术之一。 在这个国家，医疗保险已经实施了捆绑支付，以提高价值。但有 LEJR的获取和结果存在显著差异。捆绑支付可能会减少或加剧LEJR 基于种族/民族或社会经济地位的弱势患者的差异，以及这些影响 可能因参与机制而异。为弱势患者服务的医院可能不太可能参与 自愿捆绑支付计划，因为人们认为成本和结果更难影响 在这些患者中。强制性捆绑支付对弱势患者可能产生不同的影响 计划，其中医院的参与是基于决策者对成本可能性的看法 积蓄因此，政策制定者必须了解， 在医院开始参与后，弱势个体与非弱势个体的变化差异 捆绑付款。此外，了解观察到的效果如何随参与持续时间而变化， 继续与取消捆绑支付，或医院的安全网地位是关键方面， 了解政策影响。我们假设捆绑支付的医院比非捆绑支付的医院更不可能。 捆绑支付医院应位于弱势患者比例较高的市场; 与非弱势患者相比，弱势患者接受择期LEJR的可能性较低 与不参与捆绑支付的医院相比， 与非脆弱患者相比，脆弱患者的质量提高幅度较小， 在医院参与捆绑支付后，利用率和成本的下降幅度较小。

Project Summary This study examines how bundled payments implemented via voluntary and mandatory participation impact access and outcomes among vulnerable patients – evidence needed to inform policymakers about the broader policy impact and whether to scale bundled payments through voluntary and/or mandatory participation. As the largest payer for lower extremity joint replacement (LEJR), one of the fastest growing elective procedures in the country, Medicare has implemented bundled payments in an effort to improve value. However, there are marked disparities in access and outcomes for LEJR. Bundled payments could reduce or exacerbate LEJR disparities for patients who are vulnerable based on race/ethnicity or socioeconomic status, and these effects may vary by participation mechanism. Hospitals serving vulnerable patients may be less likely to participate in voluntary bundled payment programs because of perceptions that cost and outcomes are harder to influence among these patients. Different effects may occur among vulnerable patients in mandatory bundled payment programs, in which hospital participation is based on policymaker perceptions about the likelihood of cost savings. As a result, it is important for policymakers to understand whether and how access and outcomes change differentially for vulnerable versus non-vulnerable individuals after hospitals initiate participation in bundled payments. Additionally, understanding how observed effects vary by duration of participation, continuation versus disenrollment in bundled payments, or safety-net status of hospitals are key facets of understanding policy impact. We hypothesize that hospitals in bundled payments will be less likely than non- bundled payment hospitals to be located in markets with a high proportion of vulnerable patients; that compared to non-vulnerable patients, vulnerable patients will have a lower likelihood of receiving elective LEJR after hospitals start participating in bundled payments compared to hospitals that do not participate; and that compared to non-vulnerable patients, vulnerable patients will experience smaller increases in quality and smaller decreases in utilization and cost after hospital participation in bundled payments.