Cardiovascular Division, Department of Medicine, Washington University School of Medicine in St Louis, St Louis, Missouri.
Center for Health Economics and Policy, Institute for Public Health, Washington University in St Louis, St Louis, Missouri.
JAMA Health Forum. 2021 May 6;2(5):e210295. doi: 10.1001/jamahealthforum.2021.0295. eCollection 2021 May.
Medicare's Bundled Payments for Care Improvement (BPCI) program, which ran from 2013 to 2018, was an important experiment in physician-focused alternative payment models. However, little is known about whether the program was associated with better quality or outcomes or lower costs.
To determine whether participation in BPCI among physician group practices was associated with advantageous or deleterious changes in costs or patient outcomes.
This cross-sectional study used 2013 to 2017 Medicare files and difference-in-differences (DID) models to compare the change over time in Medicare payments, patient selection, and clinical outcomes between 91 orthopedic groups in BPCI Model 2 and 169 propensity-matched controls for patients undergoing joint replacement. Analyses were performed between December 2019 and February 2021.
Voluntary participation in BPCI.
The primary outcome was 90-day Medicare payments; secondary outcomes were patient selection (volume, comorbidities) and clinical outcomes (30-day and 90-day emergency department visits, readmissions, mortality, and healthy days at home).
There were 74 343 patient episodes in the baseline period and 102 790 during the intervention in BPCI practices, and 88 147 patient episodes in the baseline period and 120 253 during the intervention in control practices; 291 214 of 461 598 (63.1%) patients were women, and 419 619 (90.9%) were White. At baseline, mean episode payments among BPCI-participating practices were $18 257, which decreased to $15 320 during the intervention, while control practices decreased from $17 927 to $16 170 (DID, -$1180; 95% CI, -$1565 to -$795; < .001). Savings were driven by a decrease in postacute care spending. There were no differential changes in volume or comorbidities. The BPCI practices increased the proportion of patients discharged home compared with controls (23.6% to 43.4% vs 22.2% to 31.8%; DID, 10.2% [95% CI, 6.2% to 14.1%]). There were no differential changes in 30-day or 90-day mortality rates or emergency department visits, but 30-day and 90-day readmission rates decreased more among BPCI practices than controls (90 days: 8.7% to 7.5% vs 8.9% to 8.7%; DID, -1.0% [95% CI, -1.4% to -0.5%]), and 90-day healthy days at home increased (BPCI, 82.9 to 84.8, vs controls, 83.1 to 84.4; DID, 0.6 [95% CI, 0.4 to 0.8]).
Group practice participation in BPCI for joint replacement was associated with reduced Medicare payments and improvements in clinical outcomes.
医疗保险的捆绑支付改善计划（BPCI）从 2013 年至 2018 年实施，是一个重要的以医生为重点的替代支付模式的实验。然而，对于该计划是否与更好的质量或结果或更低的成本有关，人们知之甚少。
确定医师团体参与 BPCI 是否与成本或患者结果的有利或不利变化有关。
设计、设置和参与者：这项横断面研究使用了 2013 年至 2017 年的医疗保险文件和差分法（DID）模型，比较了在模型 2 中进行关节置换的 91 个骨科组和 169 个倾向匹配对照组之间，在医疗保险支付、患者选择和临床结果方面，在 2013 年至 2017 年期间的变化。分析于 2019 年 12 月至 2021 年 2 月进行。
自愿参与 BPCI。
主要结果是 90 天医疗保险支付；次要结果是患者选择（数量、合并症）和临床结果（30 天和 90 天急诊就诊、再入院、死亡率和在家健康天数）。
在基线期有 74343 个患者的病例，在 BPCI 实践的干预期有 102790 个病例，在对照组的基线期有 88147 个患者的病例，在干预期有 120253 个病例；461598 名患者中有 291214 名（63.1%）为女性，419619 名（90.9%）为白人。在基线时，参与 BPCI 的实践的平均每个病例的支付额为 18257 美元，在干预期间降至 15320 美元，而对照组从 17927 美元降至 16170 美元（DID，-1180；95%CI，-1565 至-795；<.001）。储蓄是由急性后护理支出减少引起的。数量和合并症没有差异变化。与对照组相比，BPCI 实践增加了出院回家的患者比例（23.6%至 43.4%比 22.2%至 31.8%；DID，10.2%[95%CI，6.2%至 14.1%]）。30 天或 90 天死亡率或急诊就诊没有差异变化，但 30 天和 90 天再入院率在 BPCI 实践中比对照组下降更多（90 天：8.7%至 7.5%比 8.9%至 8.7%；DID，-1.0%[95%CI，-1.4%至-0.5%]），90 天在家健康天数增加（BPCI，82.9 至 84.8，与对照组相比，83.1 至 84.4；DID，0.6[95%CI，0.4 至 0.8]）。
联合置换的团体实践参与 BPCI 与医疗保险支付减少和临床结果改善有关。
