UNDERSTANDING AND IMPROVING EPISODE-BASED HOSPITAL CARE

项目摘要（见说明）：各医院住院期间的支出差异很大。在我们最近的全国性研究中。在对价格差异和病例组合进行调整后，最便宜和最昂贵的五分之一医院的住院手术医疗保险支付差异为10%至39%。为了减少这种差异，CMS正在稳步向捆绑支付方向发展，这将为医院、医生和其他参与住院治疗的护理人员提供一次性支付。希望捆绑支付能给医院和医生更强的激励来协调护理，减少不必要服务的使用。扩展我们之前的p01资助的研究，该项目将探索医院支付变化的决定因素，结合来自密歇根州50家医院的65岁以下人群的索赔数据和临床丰富的结果和安全文化信息。我们还将评估医疗保险和医疗补助创新中心（CMMI）最近推出的捆绑支付计划的直接和间接后果。这个子项目有三个目标。首先，我们计划检查医院质量和医疗保险插曲付款之间的关系。利用密歇根独特的临床结果数据基础设施，我们将检查手术队列，以了解患者水平结果之间的关系，如风险调整后的发病率和死亡率，技术质量指标，如医院安全文化和团队合作，以及价格调整后的事件成本。其次，我们建议评估CMMI捆绑支付计划对成本和质量的直接影响。对于参与CMMI捆绑支付计划的密歇根医院子集，我们将评估这种干预对插曲支付和目标条件和程序的护理质量的直接影响。最后，我们计划评估插曲支付对65岁以下人群的溢出效应和替代效应，以及对患有非捆绑疾病的医疗保险患者。利用CMMI捆绑支付计划作为出院后服务相对价格的变化，我们还将评估该计划对65岁以下人群以及65岁以上人群中不相关和非目标条件的程序的溢出效应。

PROJECT SUMMARY (See Instructions): Expenditures around episodes of hospitalization vary widely across hospitals. In our recent national study. Medicare payments for inpatient surgery differed 10% to 39% between the least and most expensive hospital quintiles, after adjusting for price differences and case mix. Aiming to reduce such variation, CMS is moving steadily toward bundled payments, which would provide a single lump sum to hospitals, physicians, and other caregivers involved in care around hospitalizations. The hope is that bundled payments will give hospital and physicians stronger incentives to coordinate care and reduce the use of unnecessary services. Extending our previous P01-funded research, this project will explore determinants of variation in hospital payments, incorporating both claims data from the under-65 population and clinically rich outcomes and safety culture information from 50 hospitals in Michigan. We will also evaluate the direct and indirect consequences of the Center for Medicare and Medicaid Innovation's (CMMI) recent bundled payment initiative. This subproject has three goals. First, we plan to examine the association between hospital quality and Medicare episode payments. Taking advantage of Michigan's unique clinical outcomes data infrastructure, we will examine surgical cohorts to understand relationships among patient-level outcomes such as risk adjusted morbidity and mortality, measures of technical quality such as hospital safety culture and teamwork, and price-adjusted episode costs. Second, we propose to evaluate the direct impact of the CMMI bundled payment initiative on costs and quality. For the subset of Michigan hospitals participating in the CMMI bundled payment program, we will evaluate the direct effects of this intervention on episode payments and quality of care with targeted conditions and procedures. And finally, we plan to assess spillover and substitution effects of episode payments for the under-65 population, and for Medicare patients with unbundled conditions. Using the CMMI bundled payment program as a shift in relative prices for post discharge services, we will also assess the program's spillover effects on procedures for the under-65 population, and for unrelated and untargeted conditions in the over-65 population.