Department of Health Policy & Management, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania.
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts.
JAMA Intern Med. 2018 Feb 1;178(2):260-268. doi: 10.1001/jamainternmed.2017.7455.
In 2014, the State of Maryland placed the majority of its hospitals under all-payer global budgets for inpatient, hospital outpatient, and emergency department care. Goals of the program included reducing unnecessary hospital utilization and encouraging greater use of primary care.
To compare changes in hospital and primary care use through the first 2 years of Maryland's hospital global budget program among fee-for-service Medicare beneficiaries in Maryland vs matched control areas.
DESIGN, SETTING, AND PARTICIPANTS: We matched 8 Maryland counties (94 967 beneficiaries) with hospitals in the program to 27 non-Maryland control counties (206 389 beneficiaries). Using difference-in-differences analysis, we compared changes in hospital and primary care use in Maryland vs the control counties from before (2009-2013) to after (2014-2015) the payment change, using 2 different assumptions. First, we assumed that preintervention differences between Maryland and the control counties would have remained constant past 2014 had Maryland not implemented global budgets (parallel trend assumption). Second, we assumed that differences in preintervention trends would have continued without the payment change (differential trend assumption).
Hospital stays (defined as admissions and observation stays); return hospital stays within 30 days of a prior hospital stay; emergency department visits that did not result in admission; price-standardized hospital outpatient department (HOPD) utilization; and visits with primary care physicians (overall and within 7 days of a hospital stay).
We matched 8 Maryland counties with hospitals in the program (94 967 beneficiaries; 41.8% male; mean [SD] age, 72.3 [12.2] years) to 27 non-Maryland control counties (206 389 beneficiaries; 42.8% male; mean [SD] age, 71.7 [12.5] years). Assuming parallel trends, we estimated a differential change in Maryland of -0.47 annual hospital stays per 100 beneficiaries (95% CI, -1.65 to 0.72; P = .43) from the preintervention period (2009-2013) to 2015, but assuming differential trends, we estimated a differential change in Maryland of -1.24 stays per 100 beneficiaries (95% CI, -2.46 to -0.02; P = .047). Assuming parallel trends, we found a significant increase in primary care visits (+10.6 annual visits/100 beneficiaries; 95% CI, 4.6 to 16.6 annual visits/100 beneficiaries; P = .001), but assuming differential trends, we found no change (-0.8 visits/100 beneficiaries; 95% CI, -10.6 to 9.0 visits/100 beneficiaries; P = .87). Comparing estimates with both trend assumptions, we found no consistent changes in emergency department visits, return hospital stays, HOPD use, or posthospitalization primary care visits associated with Maryland's program.
We did not find consistent evidence that Maryland's hospital global budget program was associated with reductions in hospital use or increases in primary care visits among fee-for-service Medicare beneficiaries after 2 years. Evaluations over longer periods should be pursued.
2014 年，马里兰州将其大部分医院置于涵盖住院、医院门诊和急诊护理的全付费全球预算之下。该计划的目标包括减少不必要的住院利用和鼓励更多地使用初级保健。
在马里兰州医院全球预算计划实施的头 2 年，通过对马里兰州按服务付费的医疗保险受益人与马里兰州计划内医院的匹配控制区之间的比较，来评估医院和初级保健利用的变化。
设计、地点和参与者：我们将马里兰州的 8 个县（94967 名受益人）与计划中的医院进行匹配，与马里兰州以外的 27 个非控制县（206389 名受益人）进行匹配。使用差异-差异分析，我们使用两种不同的假设，比较了马里兰州和控制组在支付改革前后（2009-2013 年至 2014-2015 年）的医院和初级保健利用的变化情况。首先，我们假设如果马里兰州没有实施全球预算，2014 年之前马里兰州和对照组之间的预先干预差异将保持不变（平行趋势假设）。其次，我们假设如果没有支付改革，预先干预趋势的差异将继续（差异趋势假设）。
住院（定义为入院和观察住院）；30 天内再次住院的住院返回；未导致入院的急诊就诊；价格标准化的医院门诊部门（HOPD）利用率；以及与初级保健医生的就诊（总体和住院后 7 天内）。
我们将马里兰州的 8 个县与医院（94967 名受益人；41.8%为男性；平均[SD]年龄为 72.3[12.2]岁）与马里兰州以外的 27 个非控制县（206389 名受益人；42.8%为男性；平均[SD]年龄为 71.7[12.5]岁）进行了匹配。假设平行趋势，我们估计马里兰州在 2015 年的变化是与干预前（2009-2013 年）相比，每年每 100 名受益人减少 0.47 次住院（95%CI，-1.65 至 0.72；P=0.43），但假设差异趋势，我们估计马里兰州每年每 100 名受益人减少 1.24 次住院（95%CI，-2.46 至-0.02；P=0.047）。假设平行趋势，我们发现初级保健就诊明显增加（每年增加 10.6 次就诊/100 名受益人；95%CI，4.6 至 16.6 次就诊/100 名受益人；P=0.001），但假设差异趋势，我们没有发现变化（每年减少 0.8 次就诊/100 名受益人；95%CI，-10.6 至 9.0 次就诊/100 名受益人；P=0.87）。将这两种趋势假设的估计值进行比较，我们没有发现马里兰州计划与急诊就诊、住院返回、HOPD 使用或住院后初级保健就诊的任何一致变化。
我们没有发现一致的证据表明，在实施了 2 年后，马里兰州的医院全球预算计划与按服务付费的医疗保险受益人的住院利用率降低或初级保健就诊增加有关。应该进行更长时间的评估。
