Clement R Carter, Derman Peter B, Kheir Michael M, Soo Adrianne E, Flynn David N, Levin L Scott, Fleisher Lee
Orthopedics. 2016 Sep 1;39(5):e911-6. doi: 10.3928/01477447-20160623-04. Epub 2016 Jul 1.
The use of bundled payments is growing because of their potential to align providers and hospitals on the goal of cost reduction. However, such gain sharing could incentivize providers to "cherry-pick" more profitable patients. Risk adjustment can prevent this unintended consequence, yet most bundling programs include minimal adjustment techniques. This study was conducted to determine how bundled payments for total knee arthroplasty (TKA) should be adjusted for risk. The authors collected financial data for all Medicare patients (age≥65 years) undergoing primary unilateral TKA at an academic center over a period of 2 years (n=941). Multivariate regression was performed to assess the effect of patient factors on the costs of acute inpatient care, including unplanned 30-day readmissions. This analysis mirrors a bundling model used in the Medicare Bundled Payments for Care Improvement initiative. Increased age, American Society of Anesthesiologists (ASA) class, and the presence of a Medicare Major Complications/Comorbid Conditions (MCC) modifier (typically representing major complications) were associated with increased costs (regression coefficients, $57 per year; $729 per ASA class beyond I; and $3122 for patients meeting MCC criteria; P=.003, P=.001, and P<.001, respectively). Differences in costs were not associated with body mass index, sex, or race. If the results are generalizable, Medicare bundled payments for TKA encompassing acute inpatient care should be adjusted upward by the stated amounts for older patients, those with elevated ASA class, and patients meeting MCC criteria. This is likely an underestimate for many bundling models, including the Comprehensive Care for Joint Replacement program, incorporating varying degrees of postacute care. Failure to adjust for factors that affect costs may create adverse incentives, creating barriers to care for certain patient populations. [Orthopedics. 2016; 39(5):e911-e916.].
由于捆绑支付在使医疗服务提供者和医院在降低成本目标上保持一致方面具有潜力，其使用正在增加。然而，这种收益共享可能会激励医疗服务提供者“挑选”更有利可图的患者。风险调整可以防止这种意外后果，但大多数捆绑支付计划采用的调整技术很少。本研究旨在确定全膝关节置换术（TKA）的捆绑支付应如何进行风险调整。作者收集了两年内在一个学术中心接受初次单侧TKA的所有医疗保险患者（年龄≥65岁）的财务数据（n = 941）。进行多变量回归以评估患者因素对急性住院护理成本的影响，包括计划外的30天再入院情况。该分析反映了医疗保险改善护理捆绑支付计划中使用的捆绑模型。年龄增加、美国麻醉医师协会（ASA）分级以及医疗保险重大并发症/合并症（MCC）修饰符的存在（通常代表重大并发症）与成本增加相关（回归系数分别为每年57美元；超过I级的每个ASA分级为729美元；符合MCC标准的患者为3122美元；P = 0.003、P = 0.001和P < 0.001）。成本差异与体重指数、性别或种族无关。如果结果具有普遍性，对于包括急性住院护理的TKA医疗保险捆绑支付，应针对老年患者、ASA分级较高的患者以及符合MCC标准的患者按规定金额向上调整。对于许多捆绑支付模型，包括纳入不同程度急性后护理的关节置换综合护理计划，这可能是一个低估。未能对影响成本的因素进行调整可能会产生不良激励，给某些患者群体造成护理障碍。[《骨科》。2016；39(5):e911 - e916。]
