Medical Student, School of Medicine, University of Michigan, Ann Arbor.
Michigan Value Collaborative, University of Michigan, Ann Arbor.
JAMA Surg. 2018 Jan 1;153(1):14-19. doi: 10.1001/jamasurg.2017.2881.
Coronary artery bypass grafting (CABG) is scheduled to become a mandatory Medicare bundled payment program in January 2018. A contemporary understanding of 90-day CABG episode payments and their drivers is necessary to inform health policy, hospital strategy, and clinical quality improvement activities. Furthermore, insight into current CABG payments and their variation is important for understanding the potential effects of bundled payment models in cardiac care.
To examine CABG payment variation and its drivers.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study used Medicare and private payer claims to identify patients who underwent nonemergent CABG surgery from January 1, 2012, through October 31, 2015. Ninety-day price-standardized, risk-adjusted, total episode payments were calculated for each patient, and hospitals were divided into quartiles based on the mean total episode payments of their patients. Payments were then subdivided into 4 components (index hospitalization, professional, postacute care, and readmission payments) and compared across hospital quartiles. Seventy-six hospitals in Michigan representing a diverse set of geographies and practice environments were included.
Ninety-day CABG episode payments.
A total of 5910 patients undergoing nonemergent CABG surgery were identified at 33 of the 76 hospitals; of these, 4344 (73.5%) were men and mean (SD) age was 68.0 (9.3) years. At the patient level, risk-adjusted, 90-day total episode payments for CABG varied from $11 723 to $356 850. At the hospital level, the highest payment quartile of hospitals had a mean total episode payment of $54 399 compared with $45 487 for the lowest payment quartile (16.4% difference, P < .001). The highest payment quartile hospitals compared with the lowest payment quartile hospitals had 14.6% higher index hospitalization payments ($34 992 vs $30 531, P < .001), 33.9% higher professional payments ($8060 vs $6021, P < .001), 29.6% higher postacute care payments ($7663 vs $5912, P < .001), and 35.1% higher readmission payments ($3576 vs $2646, P = .06). The drivers of this variation are diagnosis related group distribution, increased inpatient evaluation and management services, higher utilization of inpatient rehabilitation, and patients with multiple readmissions.
Wide variation exists in 90-day CABG episode payments for Medicare and private payer patients in Michigan. Hospitals and clinicians entering bundled payment programs for CABG should work to understand local sources of variation, with a focus on patients with multiple readmissions, inpatient evaluation and management services, and postdischarge outpatient rehabilitation care.
冠状动脉旁路移植术（CABG）计划于 2018 年 1 月成为强制性医疗保险捆绑支付计划。为了为医疗政策、医院战略和临床质量改进活动提供信息，有必要了解 90 天 CABG 发作的支付情况及其驱动因素。此外，了解当前的 CABG 支付情况及其变化对于了解心脏护理中捆绑支付模式的潜在影响也很重要。
检查 CABG 支付的变化及其驱动因素。
设计、地点和参与者：本回顾性队列研究使用医疗保险和私人支付者的索赔数据，从 2012 年 1 月 1 日至 2015 年 10 月 31 日期间确定接受非紧急 CABG 手术的患者。对每位患者进行 90 天价格标准化、风险调整、总发作支付的计算，并根据患者的平均总发作支付将医院分为四分位数。然后将支付分为 4 个部分（索引住院、专业、后期护理和再入院支付），并在医院四分位数之间进行比较。密歇根州的 76 家医院代表了不同的地理位置和实践环境。
90 天 CABG 发作支付。
在 33 家医院中的 76 家医院中，共确定了 5910 名接受非紧急 CABG 手术的患者；其中，4344 名（73.5%）为男性，平均（SD）年龄为 68.0（9.3）岁。在患者层面，风险调整后，CABG 的 90 天总发作支付从 11723 美元到 356850 美元不等。在医院层面，支付最高四分位的医院的平均总发作支付为 54399 美元，而支付最低四分位的医院为 45487 美元（16.4%的差异，P < 0.001）。与支付最低四分位的医院相比，支付最高四分位的医院的索引住院支付高 14.6%（34992 美元对 30531 美元，P < 0.001），专业支付高 33.9%（8060 美元对 6021 美元，P < 0.001），后期护理支付高 29.6%（7663 美元对 5912 美元，P < 0.001），以及再入院支付高 35.1%（3576 美元对 2646 美元，P = 0.06）。这种变化的驱动因素是诊断相关组的分布、增加的住院评估和管理服务、更高的住院康复利用率以及多次再入院的患者。
密歇根州医疗保险和私人支付者的 90 天 CABG 发作支付存在广泛差异。参与 CABG 捆绑支付计划的医院和临床医生应努力了解当地的变化来源，重点关注多次再入院、住院评估和管理服务以及出院后门诊康复护理的患者。
