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

项目摘要 这项研究考察了通过自愿和强制参与实施的捆绑支付如何产生影响 弱势患者的可获得性和结果--向政策制定者通报更广泛的情况所需的证据 政策影响以及是否通过自愿和/或强制性参与扩大捆绑支付。作为 下肢关节置换术(LEJR)的最大付款人，这是 在这个国家，医疗保险已经实施了捆绑支付，以努力提高价值。然而，有一些 LEJR在获取机会和成果方面存在明显差异。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 可能因参与机制的不同而有所不同。为弱势患者提供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。强制捆绑支付可能会对弱势患者产生不同的影响 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，对政策制定者来说，重要的是了解是否以及如何获得机会和成果 医院开始参与后，弱势和非弱势个体的变化有所不同 捆绑付款。此外，了解观察到的效果如何随参与时间的长短而变化， 是否继续参加捆绑支付，或医院的安全网状况是关键方面 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 捆绑付费医院将设在弱势患者比例较高的市场； 与非弱势患者相比，弱势患者接受选择性LEJR的可能性较低。 在医院开始参与捆绑支付之后，与不参与的医院相比； 与非弱势患者相比，弱势患者将经历较小的质量和 医院参与捆绑支付后使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.