Robbins Keenan J, Zheng Jie, Waken R J, Orav E John, Epstein Arnold M, Joynt Maddox Karen E
Department of Surgery, Washington University School of Medicine, St Louis, Missouri.
Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts.
JAMA Netw Open. 2024 Dec 2;7(12):e2451792. doi: 10.1001/jamanetworkopen.2024.51792.
Hospital participation in the Bundled Payments for Care Improvement-Advanced (BPCI-A) initiative has been associated with modest savings and stable clinical outcomes overall, but it is unknown whether the program performs differently for medical and surgical or procedural (henceforth, surgical) episodes.
To assess the association of BPCI-A participation with Medicare spending and clinical outcomes for medical and surgical episodes.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective difference-in-differences cohort study utilized 100% Medicare fee-for-service inpatient claims for episodes initiated between January 1, 2017, and September 30, 2019, and included 90 days of follow-up. The setting was hospitals participating in BPCI-A and matched nonparticipant hospitals. Participants included Medicare beneficiaries admitted for medical or surgical episodes.
BPCI-A participation, beginning in 2018.
Changes in 90-day Medicare payments and clinical outcomes (readmissions, mortality, healthy days at home).
The final sample included 2 895 878 episodes; 1 618 172 (55.9%) were female, 324 186 (11.2%) people under age 65 years, 1 354 246 (46.8%) between 65 and 80 years of age, and 1 217 446 (42.0%) over 80 years of age. Patient characteristics at BPCI-A and comparison hospitals were similar. BPCI-A participation was associated with a decrease in payments for medical episodes (-$882 per episode; 95% CI -$1004 to -$760) and surgical episodes (-$587; 95% CI -$850 to -$324) compared with nonparticipant hospitals (absolute difference between change in medical and surgical episodes, -$295; 95% CI -$584 to -$5). BPCI-A participation was associated with a greater increase in healthy days at home and a greater decrease in both skilled nursing facility (SNF) admissions and SNF length of stay overall, but there were no significant differences between medical and surgical episodes in terms of the association of BPCI-A with changes in these outcomes.
In this cohort study analyzing the outcomes of the BPCI-A program for medical and surgical episodes, BPCI-A participation was associated with modestly decreased payments for both medical and surgical episodes compared with nonparticipants. Improvements in clinical outcomes associated with BPCI-A participation were also modest for both types of episodes; this study does not support a hypothesis that either medical or surgical episodes are better-suited for episode-based payments.
医院参与“改善护理综合支付 - 高级版”（BPCI - A）计划总体上与适度的成本节约和稳定的临床结果相关，但该计划在医疗和外科或程序性（以下简称外科）病例中的表现是否不同尚不清楚。
评估参与BPCI - A计划与医疗保险支出以及医疗和外科病例临床结果之间的关联。
设计、设置和参与者：这项回顾性差异队列研究利用了2017年1月1日至2019年9月30日期间启动的100%医疗保险按服务收费住院索赔，并进行了90天的随访。研究对象为参与BPCI - A计划的医院和匹配的非参与医院。参与者包括因医疗或外科病例入院的医疗保险受益人。
从2018年开始参与BPCI - A计划。
90天医疗保险支付的变化以及临床结果（再入院、死亡率、在家健康天数）。
最终样本包括2895878例病例；其中1618172例（55.9%）为女性，324186例（11.2%）年龄在65岁以下，1354246例（46.8%）年龄在65至80岁之间，1217446例（42.0%）年龄在80岁以上。BPCI - A计划参与医院和对照医院的患者特征相似。与非参与医院相比，参与BPCI - A计划与医疗病例支付减少（每例 - 882美元；95%置信区间 - 1004至 - 760美元）和外科病例支付减少（ - 587美元；95%置信区间 - 850至 - 324美元）相关（医疗和外科病例支付变化的绝对差异为 - 295美元；95%置信区间 - 584至 - 5美元）。参与BPCI - A计划与在家健康天数的增加幅度更大以及熟练护理机构（SNF）入院和SNF总体住院时间的减少幅度更大相关，但在BPCI - A计划与这些结果变化的关联方面，医疗和外科病例之间没有显著差异。
在这项分析BPCI - A计划在医疗和外科病例中结果的队列研究中，与未参与者相比，参与BPCI - A计划与医疗和外科病例支付适度减少相关。对于这两种类型的病例，参与BPCI - A计划相关的临床结果改善也较为适度；本研究不支持医疗或外科病例更适合按病例支付的假设。
