Department of Health Care Delivery Research, MedStar Health Research Institute, Hyattsville, MD; Department of Emergency Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC.
Pritzker School of Law and Kellogg School of Management, Northwestern University, Chicago, IL.
Ann Emerg Med. 2020 Mar;75(3):370-381. doi: 10.1016/j.annemergmed.2019.06.009. Epub 2019 Aug 24.
In 2014, Maryland launched a population-based payment model that replaced fee-for-service payments with global budgets for all hospital-based services. This global budget revenue program gives hospitals strong incentives to tightly control patient volume and meet budget targets. We examine the effects of the global budget revenue model on rates of admission to the hospital from emergency departments (EDs).
We used medical record and billing data to examine adult ED encounters from January 1, 2012, to December 31, 2015, in 25 hospital-based EDs, including 10 Maryland global budget revenue hospitals, 10 matched non-Maryland hospitals (primary control), and 5 Maryland Total Patient Revenue hospitals (secondary control). Total Patient Revenue hospitals adopted global budgeting in 2010 under a pilot Maryland program targeting rural hospitals. We conducted difference-in-differences analyses for overall ED admission rates, ED admission rates for ambulatory-care-sensitive conditions and non-ambulatory-care-sensitive conditions, and for clinical conditions that commonly lead to admission.
In 3,175,210 ED encounters, the ED admission rate for Maryland global budget revenue hospitals decreased by 0.6% (95% confidence interval -0.8% to -0.4%) compared with that for non-Maryland controls after global budget revenue implementation, a 3.0% relative decline, and decreased by 1.9% (95% confidence interval -2.2% to -1.7%) compared with that for Total Patient Revenue hospitals, a 9.5% relative decline. Relative declines in ED admission rates were similar for ambulatory-care-sensitive-condition and non-ambulatory-care-sensitive-condition encounters. Admission rate declines varied across clinical conditions.
Implementation of the global budget revenue model led to statistically significant although modest declines in ED admission rates within its first 2 years, with declines in ED admissions most pronounced among certain clinical conditions.
2014 年，马里兰州推出了一种基于人群的支付模式，用所有医院服务的总额预算取代了按服务项目收费的支付方式。该总额预算收入方案为医院提供了强有力的激励，以严格控制患者数量并达到预算目标。我们考察了总额预算收入模式对从急诊部（ED）入院率的影响。
我们使用病历和计费数据，对 2012 年 1 月 1 日至 2015 年 12 月 31 日期间 25 家医院急诊部的成年 ED 就诊情况进行了研究，其中包括 10 家马里兰州总额预算收入医院、10 家匹配的非马里兰州医院（主要对照）和 5 家马里兰州总体患者收入医院（次要对照）。总体患者收入医院于 2010 年在马里兰州针对农村医院的试点项目下采用了总额预算。我们对总体 ED 入院率、门诊治疗敏感条件和非门诊治疗敏感条件以及常见导致入院的临床情况的 ED 入院率进行了差异分析。
在 3175210 例 ED 就诊中，与非马里兰州对照相比，马里兰州总额预算收入医院在实施总额预算收入后，ED 入院率下降了 0.6%（95%置信区间-0.8%至-0.4%），相对下降了 3.0%，与总体患者收入医院相比，ED 入院率下降了 1.9%（95%置信区间-2.2%至-1.7%），相对下降了 9.5%。门诊治疗敏感条件和非门诊治疗敏感条件就诊的 ED 入院率相对下降相似。入院率的下降在不同的临床情况下有所不同。
在实施总额预算收入模式的头 2 年内，急诊部入院率出现了具有统计学意义的适度下降，在某些临床情况下，急诊部入院率的下降最为显著。
