Cardiovascular Division, Department of Medicine, Washington University School of Medicine, St Louis, Missouri.
Division of General Internal Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
J Am Geriatr Soc. 2019 Nov;67(11):2245-2253. doi: 10.1111/jgs.16147. Epub 2019 Sep 6.
BACKGROUND/OBJECTIVES: Bundled payments are an alternative payment model in which a hospital takes accountability for the costs of a 90-day episode of care. Such models are meant to improve care through better coordination across care settings, but could have adverse consequences for frail adults if they lead to inappropriate cuts in necessary post-acute care.
Retrospective claims-based analysis of hospitals' first year of participation in Medicare's Bundled Payments for Care Improvement (BPCI) program.
US hospitals.
A total of 641 146 Medicare beneficiaries admitted to 688 BPCI programs and 1276 matched control hospitals for myocardial infarction, heart failure, pneumonia, sepsis, chronic obstructive pulmonary disease, or major joint replacement of the lower extremity in 2012 to 2016.
Participation in BPCI.
Proportion of patients in each quartile of a validated claims-based frailty index, total and setting-specific standardized Medicare payments per episode, days at home, 90-day readmissions, and 90-day mortality.
Higher levels of frailty were associated with higher Medicare payments and worse clinical outcomes (for the medical composite, costs per episode were $11 921, $17 348, $22 828, and $29 157 across frailty quartiles; days at home were 70.1, 60.4, 54.3, and 51.5; 90-day readmission rates were 16.0%, 27.0%, 38.2%, and 50.9%; and 90-day mortality rates were 15.4%, 22.5%, 25.1%, 21.3%); patterns were similar for joint replacement. Under the BPCI program, there was no differential change in the proportion of highly frail patients at BPCI vs control hospitals. There were also no differential deleterious changes in payments or clinical outcomes for frail relative to nonfrail patients at BPCI vs non-BPCI hospitals.
While frail patients had higher costs and worse outcomes in general, there was no evidence of changes in access or worsening clinical outcomes in BPCI hospitals for frail patients relative to the nonfrail in hospitals' first year of participation in the program. These findings may be reassuring for policy makers and clinical leaders. J Am Geriatr Soc 67:2245-2253, 2019.
背景/目的：捆绑式支付是一种替代支付模式，在这种模式下，医院对 90 天的治疗期的成本负责。此类模式旨在通过改善跨护理环境的协调来改善护理，但如果导致对必要的急性后护理的不当削减，可能会对体弱成年人产生不利后果。
对医院参与医疗保险捆绑支付改善计划（BPCI）的第一年的基于索赔的回顾性分析。
美国医院。
2012 年至 2016 年间，共有 641146 名 Medicare 受益人与 688 个 BPCI 计划和 1276 个匹配的对照组医院因心肌梗死、心力衰竭、肺炎、败血症、慢性阻塞性肺疾病或下肢大关节置换而入院。
参与 BPCI。
验证后的基于索赔的脆弱性指数的每个四分位数中的患者比例、每个病例的总标准化 Medicare 支付额和特定环境支付额、在家天数、90 天再入院率和 90 天死亡率。
更高水平的脆弱性与更高的医疗保险支付和更差的临床结果相关（对于医疗综合指标，每个脆弱性四分位数的每例费用分别为 11921 美元、17348 美元、22828 美元和 29157 美元；在家天数分别为 70.1 天、60.4 天、54.3 天和 51.5 天；90 天再入院率分别为 16.0%、27.0%、38.2%和 50.9%；90 天死亡率分别为 15.4%、22.5%、25.1%和 21.3%）；关节置换的模式类似。在 BPCI 计划下，BPCI 医院与对照组医院的高度脆弱患者比例没有差异变化。在 BPCI 医院，与非 BPCI 医院相比，脆弱患者的支付或临床结果也没有差异恶化。
虽然脆弱患者总体上的费用更高，预后更差，但在该计划实施的第一年，BPCI 医院的脆弱患者与非脆弱患者相比，在获得医疗服务或临床预后恶化方面没有证据。这些发现可能让政策制定者和临床领导者感到放心。J Am Geriatr Soc 67：2245-2253，2019。
