Department of Health Sciences, Health Economics Section, Talma Institute, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
Department of Health Sciences, Health Economics section, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
BMC Health Serv Res. 2022 Aug 19;22(1):1061. doi: 10.1186/s12913-022-08410-7.
One of the most significant challenges of implementing a multi-provider bundled payment contract is to determine an appropriate, casemix-adjusted total bundle price. The most frequently used approach is to leverage historic care utilization based on claims data. However, those claims data may not accurately reflect appropriate care (e.g. due to supplier induced demand and moral hazard effects). This study aims to examine variation in claims-based costs of post-discharge primary care physical therapy (PT) utilization after total knee and hip arthroplasties (TKA/THA) for osteoarthritis patients.
This retrospective cohort study used multilevel linear regression analyses to predict the factors that explain the variation in the utilization of post-discharge PT after TKA or THA for osteoarthritis patients, based on the historic (2015-2018) claims data of a large Dutch health insurer. The factors were structured as predisposing, enabling or need factors according to the behavioral model of Andersen.
The 15,309 TKA and 14,325 THA patients included in this study received an average of 20.7 (SD 11.3) and 16.7 (SD 10.1) post-discharge PT sessions, respectively. Results showed that the enabling factor 'presence of supplementary insurance' was the strongest predictor for post-discharge PT utilization in both groups (TKA: β = 7.46, SE = 0.498, p-value< 0.001; THA: β = 5.72, SE = 0.515, p-value< 0.001). There were also some statistically significant predisposing and need factors, but their effects were smaller.
This study shows that if enabling factors (such as supplementary insurance coverage or co-payments) are not taken into account in risk-adjustment of the bundle price, they may cause historic claims-based pricing methods to over- or underestimate appropriate post-discharge primary care PT use, which would result in a bundle price that is either too high or too low. Not adjusting bundle prices for all relevant casemix factors is a risk because it can hamper the successful implementation of bundled payment contracts and the desired changes in care delivery it aims to support.
实施多供应商捆绑支付合同时，最具挑战性的问题之一是确定适当的、病例组合调整后的总捆绑价格。最常用的方法是利用基于索赔数据的历史护理利用情况。然而，这些索赔数据可能无法准确反映适当的护理（例如，由于供应商诱导的需求和道德风险的影响）。本研究旨在检查膝关节和髋关节骨关节炎患者全膝关节置换术和髋关节置换术后出院后初级保健物理治疗（PT）利用情况的索赔为基础的成本差异。
本回顾性队列研究使用多级线性回归分析，根据大型荷兰健康保险公司的历史（2015-2018 年）索赔数据，预测影响全膝关节置换术或髋关节置换术后骨关节炎患者出院后 PT 利用的因素。这些因素根据安德森行为模型分为倾向因素、促成因素或需要因素。
本研究共纳入 15309 例全膝关节置换术和 14325 例髋关节置换术患者，分别接受平均 20.7（SD 11.3）和 16.7（SD 10.1）次出院后 PT 治疗。结果表明，在两组中，促成因素“补充保险的存在”是出院后 PT 利用的最强预测因素（TKA：β=7.46，SE=0.498，p 值<0.001；THA：β=5.72，SE=0.515，p 值<0.001）。还有一些具有统计学意义的倾向因素和需要因素，但它们的影响较小。
本研究表明，如果在捆绑价格的风险调整中不考虑促成因素（如补充保险覆盖范围或共同支付额），它们可能导致基于历史索赔的定价方法高估或低估适当的出院后初级保健 PT 使用情况，从而导致捆绑价格过高或过低。如果不调整所有相关病例组合因素的捆绑价格，就会存在风险，因为这可能会阻碍捆绑支付合同的成功实施，以及它旨在支持的护理提供方式的预期变化。
