Departments of Public Health Sciences, Division of Health Policy and Outcomes Research.
Biostatistics and Computational Biology.
Med Care. 2021 Feb 1;59(2):101-110. doi: 10.1097/MLR.0000000000001473.
The Medicare comprehensive care for joint replacement (CJR) model, a mandatory bundled payment program started in April 2016 for hospitals in randomly selected metropolitan statistical areas (MSAs), may help reduce postacute care (PAC) use and episode costs, but its impact on disparities between Medicaid and non-Medicaid beneficiaries is unknown.
To determine effects of the CJR program on differences (or disparities) in PAC use and outcomes by Medicare-Medicaid dual eligibility status.
DESIGN, SETTING, AND PARTICIPANTS: Observational cohort study of 2013-2017, based on difference-in-differences (DID) analyses on Medicare data for 1,239,452 Medicare-only patients, 57,452 dual eligibles with full Medicaid benefits, and 50,189 dual eligibles with partial Medicaid benefits who underwent hip or knee surgery in hospitals of 75 CJR MSAs and 121 control MSAs.
Risk-adjusted differences in rates of institutional PAC [skilled nursing facility (SNF), inpatient rehabilitation, or long-term hospital care] use and readmissions; and for the subgroup of patients discharged to SNF, risk-adjusted differences in SNF length of stay, payments, and quality measured by star ratings, rate of successful discharge to community, and rate of transition to long-stay nursing home resident.
The CJR program was associated with reduced institutional PAC use and readmissions for patients in all 3 groups. For example, it was associated with reductions in 90-day readmission rate by 1.8 percentage point [DID estimate=-1.8; 95% confidence interval (CI), -2.6 to -0.9; P<0.001] for Medicare-only patients, by 1.6 percentage points (DID estimate=-1.6; 95% CI, -3.1 to -0.1; P=0.04) for full-benefit dual eligibles, and by 2.0 percentage points (DID estimate=-2.0; 95% CI, -3.6 to -0.4; P=0.01) for partial-benefit dual eligibles. These CJR-associated effects did not differ between dual eligibles (differences in above DID estimates=0.2; 95% CI, -1.4 to 1.7; P=0.81 for full-benefit patients; and -0.3; 95% CI, -1.9 to 1.3; P=0.74 for partial-benefit patients) and Medicare-only patients. Among patients discharged to SNF, the CJR program showed no effect on successful community discharge, transition to long-term care, or their persistent disparities.
The CJR program did not help reduce persistent disparities in readmissions or SNF-specific outcomes related to Medicare-Medicaid dual eligibility, likely due to its lack of financial incentives for reduced disparities and improved SNF outcomes.
从 2016 年 4 月开始，针对随机选择的大都市统计区（MSA）的医院，医疗保险综合关节置换护理（CJR）模式作为强制性捆绑支付计划，可能有助于减少术后急性护理（PAC）的使用和住院费用，但该计划对医疗保险和非医疗保险受益人的差异的影响尚不清楚。
确定 CJR 计划对医疗保险-医疗补助双重资格状态差异（或差异）对 PAC 使用和结果的影响。
设计、地点和参与者：这是一项基于 Medicare 数据的 2013-2017 年观察性队列研究，采用差异分析（DID）分析了在 75 个 CJRMSA 和 121 个对照 MSA 的医院接受髋关节或膝关节手术的 1239452 名仅接受医疗保险的患者、57452 名完全享受医疗补助福利的双重合格者和 50189 名部分享受医疗补助福利的双重合格者。
机构 PAC[熟练护理设施（SNF）、住院康复或长期医院护理]使用率和再入院率的风险调整差异；以及对于出院至 SNF 的患者亚组，风险调整的 SNF 住院时间、支付和质量差异，通过星级评定、成功出院到社区的比率和过渡到长期护理养老院居民的比率来衡量。
CJR 计划与所有 3 组患者的机构 PAC 使用和再入院率降低相关。例如，它与 90 天再入院率降低有关，仅接受医疗保险的患者降低了 1.8 个百分点（DID 估计值为-1.8；95%置信区间[CI]，-2.6 至-0.9；P<0.001），完全受益的双重合格者降低了 1.6 个百分点（DID 估计值为-1.6；95%CI，-3.1 至-0.1；P=0.04），部分受益的双重合格者降低了 2.0 个百分点（DID 估计值为-2.0；95%CI，-3.6 至-0.4；P=0.01）。这些与 CJR 相关的影响在双重合格者之间没有差异（上述 DID 估计值的差异=0.2；95%CI，-1.4 至 1.7；P=0.81，对于完全受益的患者；和-0.3；95%CI，-1.9 至 1.3；P=0.74，对于部分受益的患者）和仅接受医疗保险的患者。对于出院到 SNF 的患者，CJR 计划对成功的社区出院、过渡到长期护理或他们持续存在的差异没有影响。
CJR 计划并没有帮助减少医疗保险和医疗补助双重资格相关的再入院或 SNF 特定结果方面的持续差异，这可能是由于该计划缺乏减少差异和改善 SNF 结果的财务激励。
