Kim Hyunjee, Hart Kyle D, Meath Thomas H A, Zhu Jane M, McConnell K John
Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, Oregon.
Division of General Internal Medicine, Oregon Health & Science University, Portland, Oregon.
J Bone Joint Surg Am. 2022 Apr 6;104(7):621-629. doi: 10.2106/JBJS.21.00259. Epub 2021 Dec 13.
To improve the value and efficiency of care among traditional Medicare enrollees, the Centers for Medicare & Medicaid Services has implemented alternative payment models designed to control health-care spending and improve quality. These models may affect care beyond traditional Medicare enrollees, "spilling over" into other populations. Established in April 2016, the Medicare mandatory bundled payment program, called the Comprehensive Care for Joint Replacement (CJR) model, holds hospitals accountable for spending and quality of care for traditional Medicare joint-replacement patients during care episodes that span from the index hospitalization to 90 days post-discharge. We assessed the extent to which the CJR model was associated with outcomes for patients enrolled in commercial insurance and Medicare Advantage plans.
With use of Health Care Cost Institute claims data from 2012 through 2017, we assessed the association of the CJR model with total expenditures, discharges to institutional post-acute care, and readmissions among commercial insurance and Medicare Advantage joint-replacement patients. The exposure variable was the implementation of the CJR model in 67 randomly selected metropolitan statistical areas compared with 103 similar areas without CJR implementation. We utilized difference-in-differences models to estimate the spillover effects of the CJR model by comparing outcomes between these areas before and after CJR implementation.
The study included 174,893 joint-replacement episodes of care in commercial insurance enrollees and 202,070 episodes in Medicare Advantage enrollees. Among both commercial insurance and Medicare Advantage enrollees, CJR implementation was associated with no meaningful changes in total episode expenditures, discharges to institutional post-acute care, or readmissions.
We found no evidence for spillover effects of the CJR model on commercial insurance and Medicare Advantage patients, suggesting that alternative payment models targeting traditional Medicare patients may have limited effects on the cost and quality of care for patients outside of the traditional Medicare system.
为提高传统医疗保险参保者的医疗价值和效率，医疗保险和医疗补助服务中心实施了旨在控制医疗支出和提高质量的替代支付模式。这些模式可能会影响传统医疗保险参保者以外的医疗服务，“溢出”到其他人群。医疗保险强制性捆绑支付计划于2016年4月设立，称为全关节置换综合护理（CJR）模式，要求医院对传统医疗保险全关节置换患者从首次住院到出院后90天的护理期间的支出和护理质量负责。我们评估了CJR模式与商业保险和医疗保险优势计划参保患者的结局之间的关联程度。
利用2012年至2017年医疗保健成本研究所的理赔数据，我们评估了CJR模式与商业保险和医疗保险优势全关节置换患者的总支出、机构急性后护理出院情况和再入院之间的关联。暴露变量是在67个随机选择的大都市统计区域实施CJR模式，并与103个未实施CJR模式的类似区域进行比较。我们利用差异中的差异模型，通过比较CJR模式实施前后这些区域的结局来估计CJR模式的溢出效应。
该研究包括商业保险参保者的174,893例全关节置换护理事件和医疗保险优势参保者的202,070例护理事件。在商业保险和医疗保险优势参保者中，CJR模式的实施与总护理事件支出、机构急性后护理出院情况或再入院情况的无显著变化相关。
我们没有发现CJR模式对商业保险和医疗保险优势患者有溢出效应的证据，这表明针对传统医疗保险患者的替代支付模式可能对传统医疗保险系统以外患者的医疗成本和质量影响有限。
