RTI International, Research Triangle Park, NC.
RTI International, Waltham, MA.
Med Care. 2019 Jun;57(6):417-424. doi: 10.1097/MLR.0000000000001118.
Global budgets have been proposed as a way to control health care expenditures, but experience with them in the United States is limited. Global budgets for Maryland hospitals, the All-Payer Model, began in January 2014.
To evaluate the effect of hospital global budgets on health care utilization and expenditures.
Quantitative analyses used a difference-in-differences design modified for nonparallel baseline trends, comparing trend changes from a 3-year baseline period to the first 3 years after All-Payer Model implementation for Maryland and a matched comparison group.
Hospitals in Maryland and matched out-of-state comparison hospitals. Fee-for-service Medicare beneficiaries residing in Maryland and comparison hospital market areas.
Medicare claims were used to measure total Medicare expenditures; utilization and expenditures for hospital and nonhospital services; admissions for avoidable conditions; hospital readmissions; and emergency department visits. Qualitative data on implementation were collected through interviews with senior hospital staff, state officials, provider organization representatives, and payers, as well as focus groups of physicians and nurses.
Total Medicare and hospital service expenditures declined during the first 3 years, primarily because of reduced expenditures for outpatient hospital services. Nonhospital expenditures, including professional expenditures and postacute care expenditures, also declined. Inpatient admissions, including admissions for avoidable conditions, declined, but, there was no difference in the change in 30-day readmissions. Moreover, emergency department visits increased for Maryland relative to the comparison group.
This study provides evidence that hospital global budgets as implemented in Maryland can reduce expenditures and unnecessary utilization without shifting costs to other parts of the health care system.
全球预算已被提议作为控制医疗保健支出的一种方式，但在美国的经验有限。马里兰州医院的全球预算，即“全民支付模式”，于 2014 年 1 月开始实施。
评估医院全球预算对医疗保健利用和支出的影响。
定量分析采用了一种针对非平行基线趋势的差异中的差异设计，将马里兰州和匹配的州外对照组在全民支付模式实施前 3 年的 3 年基线期趋势变化与实施后的前 3 年趋势变化进行比较。
马里兰州的医院和匹配的州外对照组医院。居住在马里兰州和比较医院市场区域的 Medicare 按服务付费受益人。
使用 Medicare 索赔来衡量 Medicare 总支出；医院和非医院服务的利用和支出；可避免条件的住院；医院再入院；以及急诊就诊。通过对高级医院工作人员、州官员、提供者组织代表和支付方进行访谈，并对医生和护士进行焦点小组讨论，收集有关实施情况的定性数据。
在最初的 3 年中，总 Medicare 和医院服务支出下降，主要是因为门诊医院服务支出减少。非医院支出，包括专业支出和后期护理支出，也有所下降。住院入院，包括可避免条件的入院，减少，但 30 天再入院的变化没有差异。此外，与对照组相比，马里兰州的急诊就诊增加。
这项研究提供了证据表明，马里兰州实施的医院全球预算可以在不将成本转移到医疗保健系统其他部分的情况下减少支出和不必要的利用。
