Kilaru Austin S, Ng Grace Y, Wang Erkuan, Huang Erin, Crowley Aidan P, Zhu Jingsan, Liao Joshua M, Ibrahim Said, Shirk Torrey, Cousins Deborah S, Malhotra Neil R, Navathe Amol S
Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
The Parity Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia.
JAMA Health Forum. 2025 Jul 3;6(7):e251907. doi: 10.1001/jamahealthforum.2025.1907.
Few value-based payment programs have targeted outpatient surgery, although these procedures comprise most surgeries performed in hospitals. In 2018, the Centers for Medicare and Medicaid Services introduced Bundled Payments for Care Improvement Advanced (BPCI Advanced), the first episode-based payment model to include an outpatient surgical condition-spine surgery. It is not known whether bundled payments reduce spending or improve quality for outpatient surgery, despite plans to expand outpatient episodes in future models.
To determine whether hospital participation in the first year of BPCI Advanced for outpatient and inpatient spine surgery (back and neck except spinal fusion procedures [BNESF]) was associated with changes in spending and quality.
DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study using Medicare claims and differences-in-differences analysis adjusting for patient and market characteristics was conducted comparing outcomes for patients receiving outpatient and inpatient BNESF from hospitals that participated in BPCI Advanced vs those receiving these procedures from a matched comparison group of nonparticipating hospitals. Medicare beneficiaries receiving outpatient and inpatient BNESF between 2013 and 2019 were included. Analyses were conducted between March 2023 and February 2024.
Hospital participation in BPCI Advanced.
The primary outcome was total episode spending, including spending incurred for the index procedure and 90-day follow-up period. Secondary outcomes included 90-day return inpatient admissions, emergency department visits, and mortality.
Among 14 280 patients who received outpatient BNESF, hospital participation in BPCI Advanced was associated with a differential reduction in total episode spending (-$1201; 95% CI, -2184 to -219) and return inpatient admissions (-2.2 percentage points; 95% CI, -4.2 to -0.1). For outpatient procedures, the mean (SD) age was 71.8 (8.6) years; 43.9% were women, 3.9% were Black; and 3.2% were Hispanic. Among 23 440 patients who received inpatient BNESF, hospital participation in BPCI Advanced was not associated with differential changes in total episode spending or return inpatient admissions. There were no significant changes for emergency department visits or mortality for either group.
In this cohort study, participation in the first year of a bundled payment program for outpatient spine surgery was associated with nearly 10% lower spending. No changes in spending were observed for similar inpatient spine surgery procedures. Further evaluation of bundled payments for outpatient surgical conditions and associated changes in care delivery is needed to inform plans to include these episodes in future models.
尽管门诊手术占医院所做大部分手术，但很少有基于价值的支付项目针对门诊手术。2018年，医疗保险和医疗补助服务中心推出了“改善护理捆绑支付高级版”（BPCI Advanced），这是首个包含门诊手术情况（脊柱手术）的基于事件的支付模式。尽管未来模式计划扩大门诊事件范围，但尚不清楚捆绑支付是否能降低门诊手术的支出或提高质量。
确定医院参与BPCI Advanced项目第一年的门诊和住院脊柱手术（背部和颈部，不包括脊柱融合手术[BNESF]）是否与支出和质量变化相关。
设计、设置和参与者：进行了一项回顾性队列研究，使用医疗保险索赔数据，并采用差异分析来调整患者和市场特征，比较参与BPCI Advanced项目的医院中接受门诊和住院BNESF手术的患者与来自匹配的非参与医院对照组接受这些手术的患者的结局。纳入了2013年至2019年期间接受门诊和住院BNESF手术的医疗保险受益人。分析于2023年3月至2024年2月进行。
医院参与BPCI Advanced项目。
主要结局是总事件支出，包括索引手术和90天随访期产生的支出。次要结局包括90天内再次住院、急诊就诊和死亡率。
在14280例接受门诊BNESF手术的患者中，医院参与BPCI Advanced项目与总事件支出的差异减少（-1201美元；95%CI，-2184至-219）以及再次住院率的差异降低（-2.2个百分点；95%CI，-4.2至-0.1）相关。对于门诊手术，平均（标准差）年龄为71.8（8.6）岁；43.9%为女性，3.9%为黑人；3.2%为西班牙裔。在23440例接受住院BNESF手术的患者中，医院参与BPCI Advanced项目与总事件支出或再次住院率的差异变化无关。两组的急诊就诊或死亡率均无显著变化。
在这项队列研究中，参与门诊脊柱手术捆绑支付项目的第一年与支出降低近10%相关。对于类似的住院脊柱手术程序，未观察到支出变化。需要进一步评估门诊手术情况的捆绑支付以及护理提供方面的相关变化，以为未来模式中纳入这些事件的计划提供参考。
