Department of Surgery, University of Michigan, Ann Arbor, Michigan.
Center for Healthcare Outcomes and Policy, Ann Arbor, Michigan.
Dis Colon Rectum. 2019 Jun;62(6):739-746. doi: 10.1097/DCR.0000000000001372.
Bundled payment programs broaden hospitals' responsibility for spending to entire episodes of care. After demonstration programs in cardiac surgery and joint replacement, these payment reforms could soon extend to major operations like colectomy under Medicare's Bundled Payments for Care Improvement - Advanced Model.
This study aims to evaluate how specific policies and surgical practice patterns would influence hospital reimbursement in a bundled payment program for colectomy.
This was a population-based study.
We used national data from the 100% Medicare Provider Analysis and Review files for the years 2010 to 2014.
We identified patients undergoing colon resections by using diagnosis-related group codes and International Classification of Diseases, Ninth Revision, Clinical Modification codes.
We simulated per case reconciliation payments as the difference between actual price-standardized 90-day episode payments and estimated regional spending benchmarks among fee-for-service Medicare beneficiaries undergoing colectomy (2010-2014).We projected per patient and overall hospital-level reconciliation payments and the proportion of hospitals that would achieve shared savings under bundled payment conditions. We also assessed how variation in the use of laparoscopy could influence shared savings, using instrumental variable methods to account for selection bias between laparoscopic and open procedures.
Under simulated bundled payment conditions, 51.8% of hospitals would achieve shared savings, but the average case would incur a reconciliation penalty of -$234 (95% CI, -$245 to -$223). Risk adjustment would increase the proportion of hospitals with shared savings to 54.3% (per case payment, +$237; 95% CI, $96-$379). Hospitals performing a greater proportion of cases laparoscopically would achieve higher per case reconciliation payments. For example, per case reconciliation penalties would be -$472 (95% CI, -$506 to -$438) for hospitals that performed 10% of their procedures laparoscopically, whereas those that performed 70% laparoscopically would receive payments of +$294 (95% CI, $262-$326).
Alternative payment models for colectomy have not yet been introduced.
Surgical leaders must be prepared with strategies for optimizing episode efficiency. Inclusion of risk adjustment in bundled payment calculations and expanding utilization of laparoscopic surgery may represent approaches to achieve shared savings and improve surgeon engagement in alternative payment models for surgical care. See Video Abstract at http://links.lww.com/DCR/A928.
捆绑式支付计划将医院的支出责任扩大到整个护理期。在心脏手术和关节置换的示范项目之后，这些支付改革可能很快会扩展到医疗保险捆绑支付改善-高级模型下的结直肠切除术等主要手术。
本研究旨在评估特定政策和手术实践模式如何影响结直肠切除术捆绑支付计划中的医院报销。
这是一项基于人群的研究。
我们使用了 2010 年至 2014 年 100%医疗保险提供者分析和审查文件中的全国数据。
我们通过使用诊断相关组代码和国际疾病分类，第九修订版，临床修正版代码来确定接受结肠切除术的患者。
我们模拟了每例病例的和解支付，即实际价格标准化 90 天病例支付与按服务付费的医疗保险受益人接受结直肠切除术（2010-2014 年）的区域支出基准之间的差异。我们预测了每位患者和整体医院层面的和解支付，以及在捆绑支付条件下实现共享储蓄的医院比例。我们还评估了腹腔镜使用的变化如何通过使用工具变量方法来影响共享储蓄，以解决腹腔镜和开放手术之间的选择偏差。
在模拟捆绑支付条件下，51.8%的医院将实现共享储蓄，但平均每例病例将产生-234 美元的和解罚款（95%CI，-245 美元至-223 美元）。风险调整将使实现共享储蓄的医院比例增加到 54.3%（每例病例支付，+237 美元；95%CI，96 美元至 379 美元）。更多地进行腹腔镜手术的医院将获得更高的每例病例和解支付。例如，对于 10%的手术采用腹腔镜的医院，每例病例的和解罚款将为-472 美元（95%CI，-506 美元至-438 美元），而 70%的手术采用腹腔镜的医院将获得 294 美元的支付（95%CI，262 美元至 326 美元）。
结直肠切除术的替代支付模式尚未推出。
手术负责人必须准备好优化事件效率的策略。在捆绑支付计算中纳入风险调整以及扩大腹腔镜手术的使用可能是实现共享储蓄和提高外科医生参与手术护理替代支付模式的方法。在 http://links.lww.com/DCR/A928 上观看视频摘要。
