乳房重建的成本及其对基于疾病诊断相关分组的打包付费模式的影响。
The Costs of Breast Reconstruction and Implications for Episode-Based Bundled Payment Models.
机构信息
From the Section of Plastic Surgery, University of Michigan; the Division of Plastic and Reconstructive Surgery, Memorial Sloan Kettering Cancer Center; and the Center for Artificial Intelligence Research in Medicine, Chang-Gung Memorial Hospital.
出版信息
Plast Reconstr Surg. 2020 Dec;146(6):721e-730e. doi: 10.1097/PRS.0000000000007329.
BACKGROUND
Implementation of payment reform for breast reconstruction following mastectomy demands a comprehensive understanding of costs related to the complex process of reconstruction. Bundled payments for services to women with breast cancer may profoundly impact reimbursement and access to breast reconstruction. The authors' objectives were to determine the contribution of cancer therapies, comorbidities, revisions, and complications to costs following immediate reconstruction and the optimal duration of episodes to incentivize cost containment for bundled payment models.
METHODS
The cohort was composed of women who underwent immediate breast reconstruction between 2009 and 2016 from the MarketScan Commercial Claims and Encounters database. Continuous enrollment for 3 months before and 24 months after reconstruction was required. Total costs were calculated within predefined episodes (30 days, 90 days, 1 year, and 2 years). Multivariable models assessed predictors of costs.
RESULTS
Among 15,377 women in the analytic cohort, 11,592 (75 percent) underwent tissue expander, 1279 (8 percent) underwent direct-to-implant, and 2506 (16 percent) underwent autologous reconstruction. Adjuvant therapies increased costs at 1 year [tissue expander, $39,978 (p < 0.001); direct-to-implant, $34,365 (p < 0.001); and autologous, $29,226 (p < 0.001)]. At 1 year, most patients had undergone tissue expander exchange (76 percent) and revisions (81 percent), and a majority of complications had occurred (87 percent). Comorbidities, revisions, and complications increased costs for all episode scenarios.
CONCLUSIONS
Episode-based bundling should consider separate bundles for medical and surgical care with adjustment for procedure type, cancer therapies, and comorbidities to limit the adverse impact on access to reconstruction. The authors' findings suggest that a 1-year time horizon may optimally capture reconstruction events and complications.
背景
乳腺癌乳房切除术后乳房重建的支付改革需要全面了解与重建复杂过程相关的成本。针对乳腺癌女性服务的打包支付可能会对报销和获得乳房重建的机会产生深远影响。作者的目标是确定癌症治疗、合并症、翻修和并发症对即刻重建后成本的影响，并确定激励捆绑支付模式成本控制的最佳时间段。
方法
该队列由 2009 年至 2016 年期间从 MarketScan 商业索赔和就诊数据库中接受即刻乳房重建的女性组成。需要在重建前连续登记 3 个月，重建后登记 24 个月。在预定义的时间段（30 天、90 天、1 年和 2 年）内计算总费用。多变量模型评估了成本的预测因素。
结果
在分析队列的 15377 名女性中，11592 名（75%）接受了组织扩张器，1279 名（8%）接受了直接植入物，2506 名（16%）接受了自体重建。辅助治疗在 1 年时增加了成本[组织扩张器，39978 美元（p<0.001）；直接植入物，34365 美元（p<0.001）；自体重建，29226 美元（p<0.001）]。在 1 年时，大多数患者已经进行了组织扩张器更换（76%）和翻修（81%），大多数并发症已经发生（87%）。合并症、翻修和并发症增加了所有时间段的成本。
结论
基于时间段的捆绑应考虑将医疗和手术护理分开捆绑，并根据手术类型、癌症治疗和合并症进行调整，以限制对重建机会的不利影响。作者的研究结果表明，1 年的时间范围可能最优化地捕捉到重建事件和并发症。
Zotero 插件