UNDERSTANDING AND IMPROVING EPISODE-BASED HOSPITAL CARE

项目总结（见说明）：各医院住院期间的支出差异很大。在我们最近的国家研究中。在调整价格差异和病例组合后，最便宜和最昂贵的医院五分之一之间的住院手术医疗保险支付相差10%至39%。为了减少这种差异，CMS正在稳步走向捆绑支付，这将为医院、医生和其他参与住院护理的护理人员提供一次性付款。希望捆绑支付将给医院和医生更强的激励，以协调护理和减少不必要的服务的使用。扩展我们以前的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65岁以下人群的索赔数据以及来自密歇根州50家医院的临床丰富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）最近捆绑支付计划的直接和间接后果。这个分项目有三个目标。首先，我们计划研究医院质量和医疗保险事件支付之间的关联。利用密歇根州独特的临床结果数据基础设施，我们将检查手术队列，以了解患者水平的结果之间的关系，如风险调整后的发病率和死亡率，技术质量的措施，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捆绑式支付计划的密歇根州医院子集，我们将评估这种干预对事件支付和针对性条件和程序的护理质量的直接影响。最后，我们计划评估65岁以下人口和非捆绑条件的医疗保险患者的发作支付的溢出和替代效应。使用CMMI捆绑支付计划作为出院后服务相对价格的转变，我们还将评估该计划对65岁以下人群以及65岁以上人群中无关和非目标条件的溢出效应。

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.