Robinson James C, Brown Timothy T, Whaley Christopher, Bozic Kevin J
School of Public Health, University of California, 50 University Hall, MC7360, Berkeley, CA 94720-7360. E-mail address for J.C. Robinson:
Dell Medical School, University of Texas, 1912 Speedway, Suite 564, Austin, TX 78712.
J Bone Joint Surg Am. 2015 Sep 16;97(18):1473-81. doi: 10.2106/JBJS.O.00240.
Hospital-based outpatient departments traditionally charge higher prices for ambulatory procedures, compared with freestanding surgery centers. Under emerging reference-based benefit designs, insurers establish a contribution limit that they will pay, requiring the patient to pay the difference between that contribution limit and the actual price charged by the facility. The purpose of this study was to evaluate the impact of reference-based benefits on consumer choices, facility prices, employer spending, and surgical outcomes for orthopaedic procedures performed at ambulatory surgery centers.
We obtained data on 3962 patients covered by the California Public Employees' Retirement System (CalPERS) who underwent arthroscopy of the knee or shoulder in the three years prior to the implementation of reference-based benefits in January 2012 and on 2505 patients covered by CalPERS who underwent arthroscopy in the two years after implementation. Control group data were obtained on 57,791 patients who underwent arthroscopy and were not subject to reference-based benefits. The impact of reference-based benefits on consumer choices between hospital-based and freestanding facilities, facility prices, employer spending, and surgical complications was assessed with use of difference-in-differences multivariable regressions to adjust for patient demographic characteristics, comorbidities, and geographic location.
By the second year of the program, the shift to reference-based benefits was associated with an increase in the utilization of freestanding ambulatory surgery centers by 14.3 percentage points (95% confidence interval, 8.1 to 20.5 percentage points) for knee arthroscopy and by 9.9 percentage points (95% confidence interval, 3.2 to 16.7 percentage points) for shoulder arthroscopy and a corresponding decrease in the use of hospital-based facilities. The mean price paid by CalPERS fell by 17.6% (95% confidence interval, -24.9% to -9.6%) for knee procedures and by 17.0% (95% confidence interval, -29.3% to -2.5%) for shoulder procedures. The shift to reference-based benefits was not associated with a change in the rate of surgical complications. In the first two years after the implementation of reference-based benefits, CalPERS saved $2.3 million (13%) on these two orthopaedic procedures.
Reference-based benefits increase consumer sensitivity to price differences between freestanding and hospital-based surgical facilities.
This study shows that the implementation of reference-based benefits does not result in a significant increase in measured complication rates for those subject to reference-based benefits.
与独立手术中心相比，传统上医院门诊部门对门诊手术收取更高的费用。在新兴的基于参考价格的医保福利设计下，保险公司设定了他们将支付的费用上限，要求患者支付该费用上限与医疗机构实际收费之间的差额。本研究的目的是评估基于参考价格的医保福利对消费者选择、医疗机构价格、雇主支出以及在门诊手术中心进行的骨科手术的手术结果的影响。
我们获取了加利福尼亚州公共雇员退休系统（CalPERS）覆盖的3962例患者的数据，这些患者在2012年1月实施基于参考价格的医保福利前三年接受了膝关节或肩关节镜检查，以及CalPERS覆盖的2505例患者在实施后两年接受关节镜检查的数据。对照组数据来自57791例接受关节镜检查且不受基于参考价格医保福利影响的患者。使用差异中的差异多变量回归来调整患者的人口统计学特征、合并症和地理位置，评估基于参考价格的医保福利对消费者在医院和独立医疗机构之间的选择、医疗机构价格、雇主支出和手术并发症的影响。
到该计划实施的第二年，转向基于参考价格的医保福利与独立门诊手术中心的利用率增加相关，膝关节镜检查增加了14.3个百分点（95%置信区间为8.1至20.5个百分点），肩关节镜检查增加了9.9个百分点（95%置信区间为3.2至16.7个百分点），同时医院设施的使用相应减少。CalPERS支付的膝关节手术平均价格下降了17.6%（95%置信区间为-24.9%至-9.6%），肩关节手术平均价格下降了17.0%（95%置信区间为-29.3%至-2.5%）。转向基于参考价格的医保福利与手术并发症发生率的变化无关。在实施基于参考价格的医保福利后的头两年，CalPERS在这两种骨科手术上节省了230万美元（13%）。
基于参考价格的医保福利提高了消费者对独立和医院手术设施之间价格差异的敏感度。
本研究表明，实施基于参考价格的医保福利不会导致受该医保福利影响人群的并发症发生率显著增加。
