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[大学生论坛]:对关节置换实行强制捆绑支付的两年评估

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哇哈哈 发表于 2019-1-3 22:12:20 | 显示全部楼层 |阅读模式
Two-YearEvaluation of Mandatory Bundled Payments for Joint Replacement
对关节置换实行强制捆绑支付的两年评估
BACKGROUND
In2016, Medicare implemented Comprehensive Care for Joint Replacement (CJR), anational mandatory bundled-payment model for hip or knee replacement inrandomly selected metropolitan statistical areas. Hospitals in such areasreceive bonuses or pay penalties based on Medicare spending per hip- orknee-replacement episode (defined as the hospitalization plus 90 days afterdischarge).
背景:2016年,美国医疗保险制度实施了关节置换综合护理(CJR),这是一种在随机选择的大城市统计区进行髋关节或膝关节置换的国家强制支付模式。这些地区的医院根据医疗保险制度规定,根据每次髋关节或膝关节置换的医疗费用(定义为住院加出院后90天)而获得奖金或受到罚款。
METHODS
Weconducted difference-in-differences analyses using Medicare claims from 2015through 2017, encompassing the first 2 years of bundled payments in the CJRprogram. We evaluated hip- or knee-replacement episodes in 75 metropolitanstatistical areas randomly assigned to mandatory participation in the CJRprogram (bundled-payment metropolitan statistical areas, hereafter referred toas “treatment” areas) as compared with those in 121 control areas, before andafter implementation of the CJR model. The primary outcomes were institutionalspending per hip- or knee-replacement episode (i.e., Medicare payments toinstitutions, primarily to hospitals and post–acute care facilities), rates ofpostsurgical complications, and the percentage of “high-risk” patients (i.e.,patients for whom there was an elevated risk of spending — a measure of patientselection). Analyses were adjusted for the hospital and characteristics of thepatients and procedures.
方法:从2015年到2017年,我们对医疗保险制度的强制支付进行了差异化分析,涵盖了CJR计划中最初两年的捆绑支付。我们评估了75个大城市统计区的髋关节或膝关节置换事件(这些地区被随机选中强制参与CJR项目;捆绑支付的大城市统计区,以下称为“试验区”),而在121个对照区,对实施CJR模型之前和之后的情况进行了比较,比较内容是每一次髋关节或膝关节置换术的机构开支(即医疗保险支付给医疗机构,主要是给医院和重病后护理服务),术后并发症的发生率,以及“高风险”患者(即可能有巨额医疗费用的病人)的百分比。
RESULTS
From 2015 through 2017, there were280,161 hip- or knee-replacement procedures in 803 hospitals in treatment areasand 377,278 procedures in 962 hospitals in control areas. After the initiationof the CJR model, there were greater decreases in institutional spending perjoint-replacement episode in treatment areas than in control areas(differential change [i.e., the between-group difference in the change from theperiod before the CJR model], −$812, or a −3.1% differential decrease relativeto the treatment-group baseline; P<0.001). The differential reduction wasdriven largely by a 5.9% relative decrease in thepercentage of episodes in which patients were discharged to post–acute carefacilities. The CJR program did not have asignificant differential effect on the composite rate of complications (P=0.67)or on the percentage of joint-replacement procedures performed in high-riskpatients (P=0.81).
结果:从2015年到2017年,试验区有803家医院,共有280,161例髋关节或膝关节置换手术,对照区有962家医院共有377,278例。实施CJR模型后,在试验区,每例关节置换术的机构开支减少幅度大于对照组的幅度(差异变化[即与CJR模型前的组间变化],−$812,或相对于试验组基线而言,−3.1%的差减;P<0.001)。开支减少幅度的差异,主要原因是病人在术后出院转向术后护理的比例相对下降了5.9%。CJR模式对并发症的发生率和“高风险”患者的比例无显著影响。
CONCLUSIONS
Inthe first 2 years of the CJR program, there was a modest reduction in spendingper hip- or knee-replacement episode, without an increase in rates ofcomplications. (Funded by the Commonwealth Fund and the National Institute onAging of the National Institutes of Health.)
实施CJR项目的前两年里,每例髋关节或膝盖置换术的费用略有减少,而并发症的发生率没有增加。

作者:
Michael L. Barnett et al.
期刊名称:The New England Journal of Medicine.
发表时间:2019-01-02
DOI: 10.1056/NEJMsa1809010


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