Harvard Combined Orthopaedic Residency Program, Massachusetts General Hospital, Boston, MA, USA.
Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, the Netherlands.
Clin Orthop Relat Res. 2021 Nov 1;479(11):2430-2443. doi: 10.1097/CORR.0000000000001792.
The goal of bundled payments-lump monetary sums designed to cover the full set of services needed to provide care for a condition or medical event-is to provide a reimbursement structure that incentivizes improved value for patients. There is concern that such a payment mechanism may lead to patient screening and denying or providing orthopaedic care to patients based on the number and severity of comorbid conditions present associated with complications after surgery. Currently, however, there is no clear consensus about whether such an association exists.
QUESTIONS/PURPOSES: In this systematic review, we asked: (1) Is the implementation of a bundled payment model associated with a change in the sociodemographic characteristics of patients undergoing an orthopaedic procedure? (2) Is the implementation of a bundled payment model associated with a change in the comorbidities and/or case-complexity characteristics of patients undergoing an orthopaedic procedure? (3) Is the implementation of a bundled payment model associated with a change in the recent use of healthcare resources characteristics of patients undergoing an orthopaedic procedure?
This systematic review was registered in PROSPERO before data collection (CRD42020189416). Our systematic review included scientific manuscripts published in MEDLINE, Embase, Web of Science, Econlit, Policyfile, and Google Scholar through March 2020. Of the 30 studies undergoing full-text review, 20 were excluded because they did not evaluate the outcome of interest (patient selection) (n = 8); were editorial, commentary, or review articles (n = 5); did not evaluate the appropriate intervention (introduction of a bundled payment program) (n = 4); or assessed the wrong patient population (not orthopaedic surgery patients) (n = 3). This led to 10 studies included in this systematic review. For each study, patient factors analyzed in the included studies were grouped into the following three categories: sociodemographics, comorbidities and/or case complexity, or recent use of healthcare resources characteristics. Next, each patient factor falling into one of these three categories was examined to evaluate for changes from before to after implementation of a bundled payment initiative. In most cases, studies utilized a difference-in-difference (DID) statistical technique to assess for changes. Determination of whether the bundled payment initiative required mandatory participation or not was also noted. Scientific quality using the Adapted Newcastle-Ottawa Scale had a median (range) score of 8 (7 to 8; highest possible score: 9), and the quality of the total body of evidence for each patient characteristic group was found to be low using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. We could not assess the likelihood of publication using funnel plots because of the variation of patient factors analyzed in each study and the heterogeneity of data precluded a meta-analysis.
Of the nine included studies that reported on the sociodemographic characteristics of patients selected for care, seven showed no change with the implementation of bundled payments, and two demonstrated a difference. Most notably, the studies identified a decrease in the percentage of patients undergoing an orthopaedic operative intervention who were dual-eligible (range DID estimate -0.4% [95% CI -0.75% to -0.1%]; p < 0.05 to DID estimate -1.0% [95% CI -1.7% to -0.2%]; p = 0.01), which means they qualified for both Medicare and Medicaid insurance coverage. Of the 10 included studies that reported on comorbidities and case-complexity characteristics, six reported no change in such characteristics with the implementation of bundled payments, and four studies noted differences. Most notably, one study showed a decrease in the number of treated patients with disabilities (DID estimate -0.6% [95% CI -0.97% to -0.18%]; p < 0.05) compared with before bundled payment implementation, while another demonstrated a lower number of Elixhauser comorbidities for those treated as part of a bundled payment program (before: score of 0-1 in 63.6%, 2-3 in 27.9%, > 3 in 8.5% versus after: score of 0-1 in 50.1%, 2-3 in 38.7%, > 3 in 11.2%; p = 0.033). Of the three included studies that reported on the recent use of healthcare resources of patients, one study found no difference in the use of healthcare resources with the implementation of bundled payments, and two studies did find differences. Both studies found a decrease in patients undergoing operative management who recently received care at a skilled nursing facility (range DID estimate -0.50% [95% CI -1.0% to 0.0%]; p = 0.04 to DID estimate: -0.53% [95% CI -0.96% to -0.10%]; p = 0.01), while one of the studies also found a decrease in patients undergoing operative management who recently received care at an acute care hospital (DID estimate -0.8% [95% CI -1.6% to -0.1%]; p = 0.03) or as part of home healthcare (DID estimate -1.3% [95% CI -2.0% to -0.6%]; p < 0.001).
In six of 10 studies in which differences in patient characteristics were detected among those undergoing operative orthopaedic intervention once a bundled payment program was initiated, the effect was found to be minimal (approximately 1% or less). However, our findings still suggest some level of adverse patient selection, potentially worsening health inequities when considered on a large scale. It is also possible that our findings reflect better care, whereby the financial incentives lead to fewer patients with a high risk of complications undergoing surgical intervention and vice versa for patients with a low risk of complications postoperatively. However, this is a fine line, and it may also be that patients with a high risk of complications postoperatively are not being offered surgery enough, while patients at low risk of complications postoperatively are being offered surgery too frequently. Evaluation of the longer-term effect of these preliminary bundled payment programs on patient selection is warranted to determine whether adverse patient selection changes over time as health systems and orthopaedic surgeons become accustomed to such reimbursement models.
捆绑式支付 - 设计用于涵盖提供疾病或医疗事件所需的全套服务的货币总额 - 旨在提供一种报销结构，为患者提供更好的价值。有人担心，这种支付机制可能导致对患者进行筛选，并根据与手术后并发症相关的合并症数量和严重程度，拒绝或提供骨科护理。然而，目前对于是否存在这种关联尚无明确共识。
问题/目的：在这项系统评价中，我们询问：（1）实施捆绑式支付模式是否会改变接受骨科手术的患者的社会人口统计学特征？（2）实施捆绑式支付模式是否会改变接受骨科手术的患者的合并症和/或病例复杂性特征？（3）实施捆绑式支付模式是否会改变接受骨科手术的患者近期使用医疗资源的特征？
本系统评价在数据收集前在 PROSPERO 中进行了注册（CRD42020189416）。我们的系统评价包括在 MEDLINE、Embase、Web of Science、Econlit、Policyfile 和 Google Scholar 中发表的科学文献，检索时间截止至 2020 年 3 月。在经过全文审查的 30 项研究中，有 20 项因未评估研究兴趣（患者选择）（n = 8）；是社论、评论或综述文章（n = 5）；未评估适当的干预措施（引入捆绑式支付计划）（n = 4）；或评估了错误的患者人群（非骨科手术患者）（n = 3）而被排除在外。这导致了 10 项系统评价纳入的研究。对于每项研究，纳入研究中分析的患者因素被分为以下三个类别：社会人口统计学、合并症和/或病例复杂性或近期使用医疗资源的特征。接下来，检查每个属于这三个类别之一的患者因素，以评估捆绑式支付计划实施前后的变化。在大多数情况下，研究使用差异（DID）统计技术来评估变化。还注意到捆绑式支付计划是否需要强制性参与。使用改良的纽卡斯尔-渥太华量表评估科学质量的中位数（范围）评分为 8（7 至 8；最高可能评分为 9），而每个患者特征组的总证据质量使用推荐评估、发展和评估（GRADE）工具发现较低。由于每个研究中分析的患者因素存在差异，以及数据的异质性使得无法进行荟萃分析，因此我们无法使用漏斗图评估发表偏倚的可能性。
在报告接受骨科手术患者选择特征的 9 项纳入研究中，有 7 项研究表明捆绑式支付的实施没有改变，有 2 项研究表明存在差异。值得注意的是，这些研究发现接受骨科手术干预的患者中，双重资格（符合医疗保险和医疗补助保险资格）的患者比例下降（范围 DID 估计值 -0.4%[95%CI -0.75%至-0.1%]；p < 0.05 至 DID 估计值 -1.0%[95%CI -1.7%至-0.2%]；p = 0.01），这意味着他们有资格同时参加医疗保险和医疗补助保险。在报告合并症和病例复杂性特征的 10 项纳入研究中，有 6 项研究表明捆绑式支付的实施没有改变这些特征，有 4 项研究指出存在差异。值得注意的是，一项研究表明，接受捆绑式支付计划治疗的残疾患者数量减少（DID 估计值 -0.6%[95%CI -0.97%至-0.18%]；p < 0.05），而另一项研究则表明，接受捆绑式支付计划治疗的患者的 Elixhauser 合并症数量减少（治疗前：0-1 分的比例为 63.6%，2-3 分的比例为 27.9%，> 3 分的比例为 8.5%；治疗后：0-1 分的比例为 50.1%，2-3 分的比例为 38.7%，> 3 分的比例为 11.2%；p = 0.033）。在报告接受骨科手术的患者近期使用医疗资源特征的 3 项纳入研究中，有 1 项研究发现捆绑式支付的实施对医疗资源的使用没有差异，有 2 项研究发现存在差异。这两项研究都发现接受手术治疗的患者中，最近在熟练护理机构接受治疗的患者比例下降（范围 DID 估计值 -0.50%[95%CI -1.0%至 0.0%]；p = 0.04 至 DID 估计值：-0.53%[95%CI -0.96%至 -0.10%]；p = 0.01），而其中一项研究还发现最近在急性护理医院接受治疗（DID 估计值 -0.8%[95%CI -1.6%至 -0.1%]；p = 0.03）或接受家庭保健治疗（DID 估计值 -1.3%[95%CI -2.0%至 -0.6%]；p < 0.001）的接受手术治疗的患者比例下降。
在捆绑式支付计划启动后，在 10 项研究中有 6 项发现患者特征发生了差异，其影响程度较小（约 1%或更少）。然而，我们的研究结果仍表明存在一定程度的不利患者选择，从大的方面来看，这可能会加剧健康不平等。这也可能表明我们的护理更好，因为经济激励措施导致并发症风险较高的患者接受手术干预的可能性降低，反之亦然，术后并发症风险较低的患者接受手术干预的可能性增加。然而，这是一个微妙的问题，也可能是手术后并发症风险较高的患者没有得到足够的手术治疗，而术后并发症风险较低的患者则过于频繁地接受手术治疗。需要评估这些初步捆绑式支付计划对患者选择的长期影响，以确定随着医疗系统和骨科医生习惯于这种报销模式，不良患者选择是否会随时间而改变。
