Cram Peter, Ravi Bheeshma, Vaughan-Sarrazin Mary S, Lu Xin, Li Yue, Hawker Gillian
Department of Medicine, Division of General Internal Medicine, Mt Sinai/University Health Network Hospitals, University of Toronto, 200 Elizabeth Street, Eaton North, 14th Floor, Toronto, Ontario, M5G 2C4, Canada.
Department of Orthopaedics, University of Toronto, Toronto, Ontario, Canada.
Clin Orthop Relat Res. 2015 Nov;473(11):3337-47. doi: 10.1007/s11999-015-4445-0. Epub 2015 Aug 4.
Episode-of-care payments are defined as a single lump-sum payment for all services associated with a single medical event or surgery and are designed to incentivize efficiency and integration among providers and healthcare systems. A TKA is considered an exemplar for an episode-of-care payment model by many policymakers, but data describing variation payments between hospitals for TKA are extremely limited.
QUESTIONS/PURPOSES: We asked: (1) How much variation is there between hospitals in episode-of-care payments for primary TKA? (2) Is variation in payment explained by differences in hospital structural characteristics such as teaching status or geographic location, patient factors (age, sex, ethnicity, comorbidities), and discharge disposition during the postoperative period (home versus skilled nursing facility)? (3) After accounting for those factors, what proportion of the observed variation remains unexplained?
We used Medicare administrative data to identify fee-for-service beneficiaries who underwent a primary elective TKA in 2009. After excluding low-volume hospitals, we created longitudinal records for all patients undergoing TKAs in eligible hospitals encompassing virtually all payments by Medicare for a 120-day window around the TKA (30 days before to 90 days after). We examined payments for the preoperative, perioperative, and postdischarge periods based on the hospital where the TKA was performed. Confounding variables were controlled for using multivariate analyses to determine whether differences in hospital payments could be explained by differences in patient demographics, comorbidity, or hospital structural factors.
There was considerable variation in payments across hospitals. Median (interquartile range) hospital preoperative, perioperative, postdischarge, and 120-day payments for patients who did not experience a complication were USD 623 (USD 516-768), USD 13,119 (USD 12,165-14,668), USD 8020 (USD 6403-9933), and USD 21,870 (USD 19,736-25,041), respectively. Variation cannot be explained by differences in hospital structure. Median (interquartile range) episode payments were greater for hospitals in the Northeast (USD 26,291 [22,377-30,323]) compared with the Midwest, South, and West (USD 20,614, [USD 18,592-22.968]; USD 21,584, [USD 19,663-23,941]; USD 22,421, [USD 20,317-25,860]; p < 0.001) and for teaching compared with nonteaching hospitals (USD 23,152 [USD 20,426-27,127] versus USD 21,336 [USD 19,352-23,846]; p < 0.001). Patient characteristics explained approximately 15% of the variance in hospital payments, hospital characteristics (teaching status, geographic region) explained 30% of variance, and approximately 55% of variance was not explained by either factor.
There is much unexplained variation in episode-of-care payments at the hospital-level, suggesting opportunities for enhanced efficiency. Further research is needed to ensure an appropriate balance between such efficiencies and access to care.
Level II, economic analysis.
按诊疗事件付费被定义为针对与单个医疗事件或手术相关的所有服务的一次性总付款，旨在激励医疗服务提供者和医疗系统提高效率与整合度。许多政策制定者认为全膝关节置换术（TKA）是按诊疗事件付费模式的一个典范，但描述医院间TKA付费差异的数据极为有限。
问题/目的：我们提出以下问题：（1）初次TKA的按诊疗事件付费在医院间存在多大差异？（2）付费差异是否可由医院结构特征（如教学地位或地理位置）、患者因素（年龄、性别、种族、合并症）以及术后出院处置方式（回家与入住专业护理机构）的差异来解释？（3）在考虑这些因素后，观察到的差异中有多大比例仍无法解释？
我们使用医疗保险管理数据来识别2009年接受初次择期TKA的按服务收费受益人。在排除手术量少的医院后，我们为符合条件的医院中所有接受TKA的患者创建了纵向记录，涵盖医疗保险在TKA前后120天窗口内（术前30天至术后90天）的几乎所有付款。我们根据进行TKA的医院来检查术前、围手术期和出院后的付款情况。使用多变量分析控制混杂变量，以确定医院付款差异是否可由患者人口统计学、合并症或医院结构因素的差异来解释。
医院间的付款存在相当大的差异。未出现并发症的患者，医院术前、围手术期、出院后及120天付款的中位数（四分位间距）分别为623美元（516 - 768美元）、13,119美元（12,165 - 14,668美元）、8020美元（6403 - 9933美元）和21,870美元（19,736 - 25,041美元）。差异无法由医院结构差异来解释。东北部医院的按诊疗事件付款中位数（四分位间距）（26,291美元[22,377 - 30,323美元]）高于中西部、南部和西部（20,614美元，[18,592 - 22,968美元]；21,584美元，[19,663 - 23,941美元]；22,421美元，[20,317 - 25,860美元]；p < 0.001），教学医院的付款中位数（四分位间距）（23,152美元[20,426 - 27,127美元]）高于非教学医院（21,336美元[19,352 - 23,846美元]；p < 0.001）。患者特征解释了医院付款差异的约15%，医院特征（教学地位、地理区域）解释了30%的差异，约55%的差异无法由这两个因素中的任何一个来解释。
医院层面的按诊疗事件付费存在许多无法解释的差异，这表明提高效率存在机会。需要进一步研究以确保在这种效率与医疗服务可及性之间取得适当平衡。
二级，经济分析。
