Corporal Michael J. Crescenz VA Medical Center and Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (A.S.N.).
University of Washington School of Medicine, Seattle, Washington, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (J.M.L.).
Ann Intern Med. 2021 Feb;174(2):200-208. doi: 10.7326/M19-3792. Epub 2020 Dec 22.
Under the Bundled Payments for Care Improvement (BPCI) program, bundled paymtents for lower-extremity joint replacement (LEJR) are associated with 2% to 4% cost savings with stable quality among Medicare fee-for-service beneficiaries. However, BPCI may prompt practice changes that benefit all patients, not just fee-for-service beneficiaries.
To examine the association between hospital participation in BPCI and LEJR outcomes for patients with commercial insurance or Medicare Advantage (MA).
Quasi-experimental study using Health Care Cost Institute claims from 2011 to 2016.
LEJR at 281 BPCI hospitals and 562 non-BPCI hospitals.
184 922 patients with MA or commercial insurance.
Differential changes in LEJR outcomes at BPCI hospitals versus at non-BPCI hospitals matched on propensity score were evaluated using a difference-in-differences (DID) method. Secondary analyses evaluated associations by patient MA status and hospital characteristics. Primary outcomes were changes in 90-day total spending on LEJR episodes and 90-day readmissions; secondary outcomes were postacute spending and discharge to postacute care providers.
Average episode spending decreased more at BPCI versus non-BPCI hospitals (change, -2.2% [95% CI, -3.6% to -0.71%]; = 0.004), but differences in changes in 90-day readmissions were not significant (adjusted DID, -0.47 percentage point [CI, -1.0 to 0.06 percentage point]; = 0.084). Participation in BPCI was also associated with differences in decreases in postacute spending and discharge to institutional postacute care providers. Decreases in episode spending were larger for hospitals with high baseline spending but did not vary by MA status.
Nonrandomized studies are subject to residual confounding and selection.
Participation in BPCI was associated with modest spillovers in episode savings. Bundled payments may prompt hospitals to implement broad care redesign that produces benefits regardless of insurance coverage.
Leonard Davis Institute of Health Economics at the University of Pennsylvania.
在“基于价值的医保支付改革（BPCI）”计划下，对于接受医保服务的老年人群体，医保支付下的下肢关节置换术（LEJR）捆绑支付与 2%至 4%的成本节约和稳定的质量相关。然而，BPCI 可能会促使医院进行有利于所有患者的实践改变，而不仅仅是医保服务受益人群。
研究医院参与 BPCI 与拥有商业保险或 Medicare Advantage（MA）的患者的 LEJR 结果之间的关联。
使用 2011 年至 2016 年 Health Care Cost Institute 的索赔数据进行准实验研究。
281 家参与 BPCI 的医院和 562 家非 BPCI 医院进行 LEJR。
184922 名拥有 MA 或商业保险的患者。
通过倾向评分匹配，使用差异中的差异（DID）方法评估 BPCI 医院与非 BPCI 医院的 LEJR 结果的差异变化。二次分析根据患者的 MA 状态和医院特征评估关联。主要结局为 LEJR 病例 90 天总支出和 90 天再入院率的变化；次要结局为急性后支出和向急性后护理提供者的出院情况。
与非 BPCI 医院相比，BPCI 医院的 LEJR 平均病例支出下降更多（变化，-2.2%[95%CI，-3.6%至-0.71%]； = 0.004），但 90 天再入院率的变化差异无统计学意义（调整后的 DID，-0.47 个百分点[CI，-1.0 至 0.06 个百分点]； = 0.084）。参与 BPCI 还与急性后支出和向机构急性后护理提供者的出院的减少差异相关。基线支出较高的医院的病例支出减少幅度更大，但不受 MA 状态的影响。
非随机研究易受残余混杂和选择偏倚的影响。
参与 BPCI 与病例费用适度节省溢出有关。捆绑支付可能促使医院进行广泛的医疗服务重新设计，从而产生无论保险覆盖范围如何都受益的效果。
宾夕法尼亚大学 Leonard Davis 卫生经济研究所。
