Department of Surgery, Yale School of Medicine, New Haven, CT; Department of Orthopaedics & Rehabilitation, Yale School of Medicine, New Haven, CT; Center for Surgery and Public Health, Brigham and Women's Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, MA.
Division of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
J Arthroplasty. 2019 Jun;34(6):1058-1065.e4. doi: 10.1016/j.arth.2019.01.068. Epub 2019 Feb 18.
As a part of the 2010 Affordable Care Act, Medicare was committed to changing 50% of its reimbursement to alternative payment models by 2018. One strategy included introduction of "bundled payments" or a fixed price for an episode of care. Early studies of the first operative bundles for elective total hip and knee arthroplasty (THA/TKA) suggest changes in discharge to rehabilitation. It remains unclear the extent to which such changes affect patient well-being. In order to address these concerns, the objective of this study is to estimate projected changes in discharge to various type of rehabilitation, 90-day outcomes, extent of therapy received, and patient health-related quality-of-life before and after introduction of bundled payments should they be implemented on a nationwide scale.
A nationwide policy simulation was conducted using decision-tree methodology in order to estimate changes in overt and patient-centered outcomes. Model parameters were informed by published research on bundled payment effects and anticipated outcomes of patients discharged to various types of rehabilitation.
Following bundled payment introduction, discharge to inpatient rehabilitation facilities decreased by 16.9 percentage-points (95% confidence interval [CI] 16.5-17.3) among primary TKA patients (THA 16.8 percentage-points), a relative decline from baseline of 58.9%. Skilled nursing facility use fell by 24.0 percentage-points (95% CI 23.6-24.4). It was accompanied by a 36.7 percentage-point (95% CI 36.3-37.2) increase in home health agency use. Although simulation models predicted minimal changes in overt outcome measures such as unplanned readmission (TKA +0.8 percentage-points), changes in discharge disposition were accompanied by significant increases in the need for further assistive care (TKA +8.0 percentage-points) and decreases in patients' functional recovery and extent of therapy received. They collectively accounted for a 30% reduction in recovered motor gains.
The results demonstrate substantial changes in discharge to rehabilitation with accompanying declines in average functional outcomes, extent of therapy received, and health-related quality-of-life. Such findings challenge notions of reduced cost at no harm previously attributed to the bundled payment program and lend credence to concerns about reductions in access to facility-based rehabilitation.
作为 2010 年平价医疗法案的一部分，医疗保险承诺到 2018 年将其 50%的报销改为替代支付模式。其中一项策略包括引入“捆绑支付”或某项医疗服务的固定价格。早期对选择性全髋关节和膝关节置换术（THA/TKA）首个手术捆绑包的研究表明，出院后可进行康复治疗。但目前尚不清楚这些变化在多大程度上影响了患者的健康状况。为了解决这些问题，本研究旨在估计如果在全国范围内实施捆绑支付，对各种类型的康复、90 天的结果、治疗程度以及患者健康相关生活质量的预期变化。
采用决策树方法进行全国性政策模拟，以估计显性和以患者为中心的结果的变化。模型参数来源于捆绑支付效果的已发表研究和对各种康复类型出院患者的预期结果。
在捆绑支付引入后，初次 TKA 患者（THA 为 16.8 个百分点）的住院康复机构出院率下降了 16.9 个百分点（95%置信区间[CI]为 16.5-17.3），相对于基线下降了 58.9%。熟练护理机构的使用率下降了 24.0 个百分点（95% CI 为 23.6-24.4）。这伴随着家庭健康机构使用量增加了 36.7 个百分点（95% CI 为 36.3-37.2）。尽管模拟模型预测在无计划再入院等显性结果测量上的变化很小（TKA 为 0.8 个百分点），但出院处置的变化伴随着对进一步辅助护理的需求显著增加（TKA 为 8.0 个百分点）和患者功能恢复和治疗程度的下降。它们共同导致了恢复运动增益减少 30%。
结果表明，康复出院方面发生了重大变化，同时平均功能结果、治疗程度和健康相关生活质量下降。这些发现挑战了以前归因于捆绑支付计划的减少成本而无伤害的观念，并为人们对减少获得机构康复服务的机会的担忧提供了依据。
