Impact of Bundled Payment Reforms on Racial and Socioeconomic Disparities in Hip and Knee Replacement Surgeries

项目摘要： 老年医疗保险受益人的髋关节和膝关节置换手术具有重要的临床意义 考虑到它们对晚期骨关节炎的有效性；以及由于其高度的 需求的数量、支出和预期增长。照顾儿童方面的种族和社会经济差异 这些手术都有很好的记录。我们的初步分析和其他研究表明， 与白人相比，黑人接受这些手术的频率较低，结果也较差，而且 来自较低社会经济阶层的患者比来自较高社会经济阶层的患者面临更大的障碍。 在他们接触到这些手术的时候。2016年，医疗保险和医疗补助服务中心推出了 关节置换综合护理(CJR)模式，这是一种捆绑支付改革， 捆绑/包括与这些手术相关的大部分支出(从住院开始，继续 急诊后护理，出院后90天结束)在一次手术中。 因此，医院、临床医生和急诊后护理机构在财政上受到激励，以改善 协调不同环境的护理，使他们的支出保持在较低水平，并达到重要的质量基准。 然而，专家们担心，在缺乏旨在缩小差距的指标的情况下，设计 CJR的存在可能会加剧不同种族患者在髋关节和膝关节置换护理方面的差异 和社会经济类别，以及为不同比例的少数族裔患者提供服务的医院。这些 担忧有相当大的表面有效性，但总体上捆绑支付的影响，以及CJR在 特别是，关于差距的问题还没有得到实证评估。鉴于经验主义文献中的这些空白， 我们建议的目的是评估CJR对种族和社会经济利用差距的影响 (目标1)、住院结果(目标2)和急性后护理结果(目标3)髋关节和膝关节置换护理。 此外，我们将确定影响CJR对差异的影响的关键机制，并调查是否 我们预期的结果和差异的变化是通过选择急性后护理机构来调节的 病人出院(目标4)。这些目标的最主要的理由是，为了追求财政 CJR的回报，医院可能会避免病情较重的患者，其中许多可能是种族和 社会经济少数群体；医院、临床医生和急性后护理机构将采取降低成本的措施 可能针对少数族裔患者并对其产生不利影响的战略，从而加剧差异。我们会 使用国家数据进行严格的纵向分析，以解决特定目标和相关测试 假设。我们从研究中获得的知识将为当前和未来捆绑的设计提供参考 支付改革，以使这些改革能够防止恶化，并有助于减少现有的 髋关节和膝关节置换手术中的种族和社会经济差异。

Project Abstract: Hip and knee replacement surgeries for elderly Medicare beneficiaries have important clinical implications given their effectiveness for advanced osteoarthritis; and important financial implications given their high volume, expenditure, and expected growth in demand. Racial and socioeconomic disparities in the care of these surgeries are well-documented. Our preliminary analysis and other studies have demonstrated that blacks undergo these surgeries less frequently and have poorer outcomes as compared to whites, and that patients from lower socioeconomic strata face greater barriers than those from the upper socioeconomic strata in their access to these surgeries. In 2016, the Centers for Medicare and Medicaid Services introduced the Comprehensive Care for Joint Replacement (CJR) Model, which is a bundled payment reform that bundles/includes most spending related to these surgeries (beginning with the inpatient stay, continuing to post-acute care, and ending 90 days after discharge from the hospital) under a single surgical episode. Hospitals, clinicians and post-acute care facilities are therefore financially incentivized to improve the coordination of care across settings, to keep their spending low and to meet important quality benchmarks. However, experts have raised concerns that in the absence of metrics aimed at reducing disparities, the design of the CJR is likely to exacerbate disparities in hip and knee replacement care across patients of different racial and socioeconomic categories, and across hospitals that serve varying proportions of minority patients. These concerns have considerable face validity, yet the impact of bundled payments in general, and the CJR in particular, on disparities has not been empirically evaluated. In light of these gaps in empirical literature, the aims of our proposal are to evaluate the impact of the CJR on racial and socioeconomic disparities in utilization (Aim 1), inpatient outcomes (Aim 2), and post-acute care outcomes (Aim 3) of hip and knee replacement care. Furthermore, we will identify key mechanisms that influence CJR's impact on disparities, and investigate if the changes in outcomes and disparities that we expect are mediated by the choice of post-acute care facility to which a patient is discharged (Aim 4). The overarching rationale for these aims is that in pursuit of financial rewards from the CJR, hospitals are likely to avoid sicker patients, many of whom are likely to be racial and socioeconomic minorities; and hospitals, clinicians, and post-acute care facilities will adopt cost-reduction strategies that may target and adversely influence minority patients, thereby exacerbating disparities. We will conduct rigorous longitudinal analyses using national data to address the specific aims and test associated hypotheses. The knowledge gained from our study will inform the design of current and future bundled payment reforms such that these reforms can prevent the exacerbation of and contribute in reducing existing racial and socioeconomic disparities in hip and knee replacement surgeries."