基于质量的医保支付和肝胰外科报销率的变化：高质量医院是否有经济激励？

Variation in Medicare Payments and Reimbursement Rates for Hepatopancreatic Surgery Based on Quality: Is There a Financial Incentive for High-Quality Hospitals?

机构信息

Department of Surgery, Ohio State University, Wexner Medical Center, Columbus, OH.

出版信息

J Am Coll Surg. 2018 Aug;227(2):212-222.e2. doi: 10.1016/j.jamcollsurg.2018.04.005. Epub 2018 Apr 20.

DOI:10.1016/j.jamcollsurg.2018.04.005

PMID:29680412

Abstract

BACKGROUND

To better define the financial impact of high-quality care for payers and hospitals, we compared outcomes and Medicare payments between high-quality (HQ) and low-quality (LQ) hospitals after hepatopancreatic surgery.

STUDY DESIGN

Between 2013 through 2015, a total of 15,874 Medicare beneficiaries underwent hepatopancreatic surgery. Using the entire cohort, multivariable logistic regression was performed to categorize hospitals into quintiles based on the probability of experiencing a major complication; HQ (bottom 20%) and LQ (top 20%) hospitals were identified. Only HQ and LQ hospitals were included in the final propensity matching to compare payments. Major complication was defined as a complication associated with a length of stay of >75th percentile. Incremental payment and cost of complication were estimated using multivariable linear regression.

RESULTS

Major complications occurred in 9.7% (n = 309 of 3,182) at HQ hospitals compared with 20% (n = 625 of 3,130) at LQ hospitals (p < 0.001). The incremental increased payment associated with major complication was $29,640, which was lower than the incremental hospital cost of $42,935. The Medicare reimbursement rate was also 6% lower at both HQ and LQ hospitals when a major complication occurred vs not; however, HQ hospitals had a 3% higher reimbursement rate compared with LQ hospitals when a major complication did not occur (p = 0.002). Mean unadjusted Medicare payment was lower at HQ hospitals by $5,165 per patient vs LQ hospitals (p < 0.001), largely because HQ hospitals had a lower overall incidence of major complications (n = 315 vs n = 625). By having 310 fewer patients with a major complication, HQ hospitals collectively achieved $3.1 million/year in Medicare savings.

CONCLUSIONS

High-quality hospitals are able to achieve substantial Medicare savings by avoiding major complications. Occurrence of major complications was associated with lower Medicare reimbursement rates at both HQ and LQ hospitals vs when no complications occurred.

摘要

背景

为了更好地为支付方和医院定义高质量护理的经济影响，我们比较了肝胰手术治疗后高质量（HQ）和低质量（LQ）医院的结果和医疗保险支付情况。

研究设计

在 2013 年至 2015 年期间，共有 15874 名 Medicare 受益人接受了肝胰手术。使用整个队列，进行多变量逻辑回归分析，根据经历主要并发症的可能性将医院分为五分位数；根据 HQ（底部 20%）和 LQ（顶部 20%）医院进行分类。仅 HQ 和 LQ 医院被纳入最终倾向匹配以比较支付情况。主要并发症定义为与住院时间 >75 百分位数相关的并发症。使用多变量线性回归估计增量支付和并发症成本。

结果

HQ 医院的主要并发症发生率为 9.7%（3182 例中的 309 例），而 LQ 医院的主要并发症发生率为 20%（3130 例中的 625 例）（p<0.001）。与主要并发症相关的增量支付增加了 29640 美元，低于增量医院成本 42935 美元。当发生主要并发症时，HQ 和 LQ 医院的医疗保险报销率也分别降低了 6%；然而，当未发生主要并发症时，HQ 医院的报销率比 LQ 医院高 3%（p=0.002）。与 LQ 医院相比，HQ 医院每位患者的未经调整的 Medicare 支付平均低 5165 美元（p<0.001），这主要是因为 HQ 医院主要并发症的总体发生率较低（315 例 vs. 625 例）。通过减少 310 例主要并发症患者，HQ 医院每年可节省 Medicare 310 万美元。