Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
Healthc (Amst). 2020 Dec;8(4):100447. doi: 10.1016/j.hjdsi.2020.100447. Epub 2020 Oct 28.
Medicare used the Comprehensive Care for Joint Replacement (CJR) Model to mandate that hospitals in certain health care markets accept bundled payments for lower extremity joint replacement surgery. CJR has reduced spending with stable quality as intended among Medicare fee-for-service patients, but benefits could "spill over" to individuals insured through private health plans. Definitive evidence of spillovers remains lacking.
To evaluate the association between CJR participation and changes in outcomes among privately insured individuals.
DESIGN, SETTING, PARTICIPANTS: We used 2013-2017 Health Care Cost Institute claims for 418,016 privately insured individuals undergoing joint replacement in 75 CJR and 121 Non-CJR markets. Multivariable generalized linear models with hospital and market random effects and time fixed effects were used to analyze the association between CJR participation and changes in outcomes.
Total episode spending, discharge to institutional post-acute care, and quality (e.g., surgical complications, readmissions).
Patients in CJR and Non-CJR markets did not differ in total episode spending (difference of -$157, 95% CI -$1043 to $728, p = 0.73) or discharge to institutional post-acute care (difference of -1.1%, 95% CI -3.2%-1.0%, p = 0.31). Similarly, patients in the two groups did not differ in quality or other utilization outcomes. Findings were generally similar in stratified and sensitivity analyses.
There was a lack of evidence of cost or utilization spillovers from CJR to privately insured individuals. There may be limits in the ability of certain value-based payment reforms to drive broad changes in care delivery and patient outcomes.
医疗保险采用综合关节置换护理（CJR）模式，要求某些医疗市场中的医院接受下肢关节置换手术的捆绑式支付。CJR 降低了医疗保险按服务收费患者的支出，同时保持了预期的质量，但好处可能“溢出”到通过私人健康计划投保的个人。确切的溢出证据仍然缺乏。
评估 CJR 参与与私人保险个人结果变化之间的关联。
设计、环境、参与者：我们使用 2013-2017 年健康成本协会的索赔数据，对 75 个 CJR 和 121 个非 CJR 市场中接受关节置换手术的 418016 名私人保险个人进行了分析。使用带有医院和市场随机效应和时间固定效应的多变量广义线性模型来分析 CJR 参与与结果变化之间的关联。
总疗程支出、向机构性后期护理的出院情况和质量（例如，手术并发症、再入院）。
CJR 和非 CJR 市场的患者在总疗程支出方面没有差异（差异为-157 美元，95%置信区间-1043 美元至 728 美元，p=0.73）或向机构性后期护理的出院情况（差异为-1.1%，95%置信区间-3.2%至-1.0%，p=0.31）。同样，两组患者在质量或其他使用结果方面也没有差异。分层和敏感性分析的结果基本相似。
缺乏 CJR 向私人保险个人产生成本或使用溢出的证据。某些基于价值的支付改革可能在推动广泛的护理提供和患者结果变化方面存在限制。
