Rush University Medical Center, Department of Orthopaedic Surgery, Chicago, Illinois.
J Arthroplasty. 2017 Nov;32(11):3263-3267. doi: 10.1016/j.arth.2017.05.035. Epub 2017 May 25.
Although some bundled payment models have had success in total joint arthroplasty, concerns exist about access to care for higher cost patients who use more resources. The purpose of this study is to determine whether Medicaid patients have increased hospital costs and more resource utilization in a 90-day episode of care than Medicare or privately insured patients.
We retrospectively reviewed a consecutive series of 7268 primary hip and knee arthroplasty patients at a single institution. Using a propensity score-matching algorithm for demographic variables, we matched the 92 consecutive Medicaid patients with 184 privately insured and 184 Medicare patients. Hospital-specific costs, discharge disposition, complications, and 90-day readmissions were analyzed.
Medicaid patients had higher mean inpatient hospital costs than both of the matched Medicare and privately insured groups ($15,396 vs $12,165 vs $13,864, P < .001) with longer length of stay (3.34 vs 2.49 vs 1.46 days, P < .001). Medicaid and Medicare patients were more likely to be discharged to a rehabilitation facility than privately insured patients (17% vs 21% vs 1%, P < .001). When controlling for demographic factors and comorbidities, Medicaid insurance was a significant independent risk factor for increased hospital costs (odds ratio 3.64, 95% confidence interval 1.80-7.38, P < .001).
Because of increased hospital costs, current bundled payment models should not include Medicaid patients because of concerns about patient selection and access to care. Further study is needed to determine whether bundling Medicaid arthroplasty costs in a stand-alone program with a separate target price will result in improved outcomes and decreased costs.
虽然一些打包付费模式在全膝关节置换术方面取得了成功，但对于使用更多资源的高成本患者的医疗服务可及性仍存在担忧。本研究旨在确定在 90 天的治疗期间，医疗补助（Medicaid）患者的住院费用是否高于医疗保险（Medicare）或私人保险患者，以及资源利用率是否更高。
我们回顾性分析了一家机构的 7268 例连续原发性髋关节和膝关节置换术患者。通过对人口统计学变量的倾向评分匹配算法，我们将 92 例连续的 Medicaid 患者与 184 例私人保险患者和 184 例 Medicare 患者进行匹配。分析了医院特定费用、出院去向、并发症和 90 天再入院率。
与匹配的 Medicare 和私人保险组相比，Medicaid 患者的住院医院费用更高（$15396 比$12165 比$13864，P<0.001），住院时间更长（3.34 天比 2.49 天比 1.46 天，P<0.001）。与私人保险患者相比，Medicaid 和 Medicare 患者更有可能被送往康复机构（17%比 21%比 1%，P<0.001）。在控制了人口统计学因素和合并症后，Medicaid 保险是导致住院费用增加的显著独立危险因素（优势比 3.64，95%置信区间 1.80-7.38，P<0.001）。
由于住院费用增加，当前的打包付费模式不应包括 Medicaid 患者，因为这涉及到患者选择和医疗服务可及性的问题。需要进一步研究，以确定将 Medicaid 关节置换费用纳入单独目标价格的独立计划中是否会改善结果并降低成本。
