Leonard Davis School of Gerontology, University of Southern California, Los Angeles.
USC Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California.
JAMA Netw Open. 2024 Sep 3;7(9):e2433962. doi: 10.1001/jamanetworkopen.2024.33962.
The Comprehensive Care for Joint Replacement (CJR) model, a traditional Medicare bundled payment program for lower-extremity joint replacement, is associated with care for patients outside traditional Medicare. Whether CJR model outcomes have differed by patient race or ethnicity outside of traditional Medicare is unclear.
To evaluate outcomes associated with the CJR model among Hispanic patients not enrolled in traditional Medicare.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used hospitalization data from California's Patient Discharge Dataset for all patients who underwent lower-extremity joint replacement in California between January 1, 2014, and December 31, 2017. In California, 3 metropolitan statistical areas (MSAs) were randomly selected to participate in CJR in April 2016. Hospitals not participating in other Medicare Alternative Payment Models were included in the treated group if they were in these 3 MSAs and in the control group if they were in the remaining 23 MSAs. The data analysis was performed between October 1 and December 31, 2023.
Comprehensive Care for Joint Replacement program implementation.
The main outcomes were hospital length of stay and home discharge rates by race and ethnicity. Home discharge status included self-care, the use of home health services, and hospice care at home. Event study, difference-in-differences, and triple differences models were used to estimate differential changes in health care service use by race and ethnicity for patients in the treated MSAs compared with the control MSAs before vs after CJR implementation.
Of 309 834 hospitalizations (patient mean [SD] age, 68.3 [11.3] years; 60.6% women; 14.8% Hispanic; 72.4% non-Hispanic White), 48.0% were in treated MSAs and 52.0% in control MSAs. The CJR program was associated with an increase in home discharge rates for patients without traditional Medicare coverage; however, the increase differed by patient race and ethnicity. The increase was 0.05 (95% CI, 0.02-0.08) percentage points higher for Hispanic patients with Medicare Advantage and 0.03 (95% CI, 0.01-0.04) percentage points higher for Hispanic patients without Medicare compared with their non-Hispanic White counterparts.
This cohort study shows that CJR program outcomes differed by race and ethnicity for patients covered outside traditional Medicare, with home discharge rates increasing more for Hispanic compared with non-Hispanic White patients. These findings suggest the importance of considering differential outcomes of Medicare payment policies for racial and ethnic minority patient populations beyond the initially targeted groups.
综合关节置换护理（CJR）模式是一种针对下肢关节置换的传统医疗保险捆绑支付计划，与医疗保险以外的患者护理有关。CJR 模式的结果是否因医疗保险以外的患者的种族或族裔而有所不同尚不清楚。
评估 CJR 模式在未参加传统医疗保险的西班牙裔患者中的结果。
设计、地点和参与者：本队列研究使用了加利福尼亚州患者出院数据集在加利福尼亚州接受下肢关节置换手术的所有患者的住院数据，时间为 2014 年 1 月 1 日至 2017 年 12 月 31 日。加利福尼亚州有 3 个都会统计区（MSA）于 2016 年 4 月被随机选中参加 CJR。如果医院未参与其他医疗保险替代支付模式，且位于这 3 个 MSA 中，则将其纳入治疗组；如果医院位于其余 23 个 MSA 中，则将其纳入对照组。数据分析于 2023 年 10 月 1 日至 12 月 31 日进行。
综合关节置换护理计划的实施。
主要结局是根据种族和族裔的住院时间和家庭出院率。家庭出院状况包括自理、家庭健康服务的使用以及在家中的临终关怀。采用事件研究、差异中的差异和三重差异模型，估计在 CJR 实施前后，治疗 MSA 与对照 MSA 中患者的种族和族裔对医疗服务使用的差异变化。
在 309834 例住院治疗中（患者平均[标准差]年龄为 68.3[11.3]岁；60.6%为女性；14.8%为西班牙裔；72.4%为非西班牙裔白人），48.0%来自治疗 MSA，52.0%来自对照 MSA。CJR 计划与未参加传统医疗保险的患者的家庭出院率增加有关；然而，这种增加因患者的种族和族裔而异。与非西班牙裔白人患者相比，参加医疗保险优势计划的西班牙裔患者的增加幅度高 0.05（95%CI，0.02-0.08）个百分点，未参加医疗保险的西班牙裔患者的增加幅度高 0.03（95%CI，0.01-0.04）个百分点。
本队列研究表明，对于医疗保险覆盖范围以外的患者，CJR 计划的结果因种族和族裔而异，与非西班牙裔白人患者相比，西班牙裔患者的家庭出院率增加更多。这些发现表明，在最初目标群体之外，考虑医疗保险支付政策对少数民族患者群体的不同结果的重要性。
