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[大学生论坛]:关节置换术强制性捆绑支付的两年期评估

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Winnie123 发表于 2019-1-3 23:04:59 | 显示全部楼层 |阅读模式
本帖最后由 Winnie123 于 2019-1-3 23:09 编辑

Two-Year Evaluation of Mandatory Bundled Payments for Joint Replacement
关节置换术强制性捆绑支付的两年期评估
Abstract
摘要
BACKGROUND
背景
In 2016, Medicare implemented Comprehensive Care for Joint Replacement (CJR), a national mandatory bundled-payment model for hip or knee replacement in randomly selected metropolitan statistical areas. Hospitals in such areas receive bonuses or pay penalties based on Medicare spending per hip- or knee-replacement episode (defined as the hospitalization plus 90 days after discharge).
2016年,美国医疗保险实施了关节置换综合护理(CJR),该措施针是置换髋关节或膝关节的国家强制性捆绑支付模式,在随机选择的大都市统计予以实施。这些地区的医院根据每次髋关节或膝关节置换术的医疗保险支出(期限为住院加上出院后90天)获得奖金或支付罚金。
METHODS
方法
We conducted difference-in-differences analyses using Medicare claims from 2015 through 2017, encompassing the first 2 years of bundled payments in the CJR program.
我们对2015年至2017年的医疗保险索赔进行了差异分析,包括CJR计划中第一、第二的捆绑支付数据。
We evaluated hip- or knee-replacement episodes in 75 metropolitan statistical areas randomly assigned to mandatory participation in the CJR program (bundled-payment metropolitan statistical areas, hereafter referred to as “treatment” areas) as compared with those in 121 control areas, before and after implementation of the CJR model.
我们将75个随机参与CJR计划的城市(即捆绑支付大城市统计区域,以下称为“治疗”区域)的髋关节或膝关节置换数据汇总,进行评估,与实施CJR模型前、及实施后的121个控制区域的数据作对比。
The primary outcomes were institutional spending per hip- or knee-replacement episode (i.e., Medicare payments to institutions, primarily to hospitals and post–acute care facilities), rates of postsurgical complications, and the percentage of “high-risk” patients (i.e., patients for whom there was an elevated risk of spending — a measure of patient selection). Analyses were adjusted for the hospital and characteristics of the patients and procedures.
得出的主要结果是平均每次髋关节或膝关节置换术的机构支出(即医疗保险支付给医院和急症护理机构等机构),还得出术后并发症发生率和“高风险”患者的百分比(即风险不断增高的患者 - 此为选择患者的衡量标准。此外,还根据患者和手术的特征,调整分析结果。
RESULTS
结果
From 2015 through 2017, there were 280,161 hip- or knee-replacement procedures in 803 hospitals in treatment areas and 377,278 procedures in 962 hospitals in control areas.
据统计,从2015年到2017年,治疗区803家医院进行了280,161次髋关节或膝关节置换手术,控制区962家医院进行377,278次手术。
After the initiation of the CJR model, there were greater decreases in institutional spending per joint-replacement episode in treatment areas than in control areas (differential change [i.e., the between-group difference in the change from the period before the CJR model], −$812, or a −3.1% differential decrease relative to the treatment-group baseline; P<0.001). The differential reduction was driven largely by a 5.9% relative decrease in the percentage of episodes in which patients were discharged to post–acute care facilities.
在实施CJR模型后,结果显示治疗区每台关节置换手术的机构支出比对照区域大(差异变化[即,CJR模型之前的变化之间的组间差异],  - 相对于治疗组基线是812美元,或相差-3.1%; P <0.001)。 差异减少主要是由于患者出院转至急性发病期后护理机构的百分比相对减少5.9%。
The CJR program did not have a significant differential effect on the composite rate of complications (P=0.67) or on the percentage of joint-replacement procedures performed in high-risk patients (P=0.81).
CJR项目对与发症的综合率(P = 0.67)或高危患者的关节置换手术百分比的影响并没有显着差异(P = 0.81)。

CONCLUSIONS
结论
In the first 2 years of the CJR program, there was a modest reduction in spending per hip- or knee-replacement episode, without an increase in rates of complications. (Funded by the Commonwealth Fund and the National Institute on Aging of the National Institutes of Health.)
在实施CJR计划的前两年,每次髋关节或膝关节置换术的支出都在适度减少,而并发症的发生率却没有增加。(由英联邦基金会和国家卫生研究院老龄化研究所资助。)
In April 2016, Medicare initiated Comprehensive Care for Joint Replacement (CJR), a mandatory bundled-payment model for inpatient replacement of the hip or knee.1 In the CJR program, hospitals are held accountable for spending for an episode of care, which includes the index hospitalization for the procedure plus all spending (with minor exceptions specified by the Centers for Medicare and Medicaid Services) in the 90 days after discharge.2 In contrast to the voluntary nature of other alternative payment models, CJR randomly assigns metropolitan statistical areas to mandatory participation.3,4 Hospitals in areas that are randomly assigned to the CJR program are subject to bundled payments for all episodes of hip or knee replacement.
2016年4月,医疗保险启动了全面关节置换护理计划(CJR),这是一种强制性的捆绑式支付模式,给住院病人更换髋关节或第一节膝关节。在CJR计划实施过程中,医院负责支付护理费用,其中包括在出院后90天内,该项目的住院指数加上所有支出(也包括医疗保险和医疗补助服务中心规定的少数例外情况)。与其他替代支付模式的自愿性相比,随机分配实施CJR的大都市统计区域需强制参与,.3,4随机分配CJR计划地区的3、4家医院均需要支付所有髋关节或膝关节置换术的捆绑费用。
Like other bundled-payment programs,5,6 CJR was designed to provide financial incentives for hospitals to reduce spending without compromising quality across an entire episode of care during the index hospitalization and after discharge. During a CJR episode, fee-for-service payments are made as usual to all providers (e.g., outpatient physicians or skilled nursing facilities). Participating hospitals then undergo an annual retrospective reconciliation process in which their average spending per episode is compared with a hospital-specific benchmark. Hospitals share savings with Medicare if spending falls below the benchmark or, starting in 2017, they pay a penalty if spending exceeds the target.1,2 As with the accountable care organization programs in Medicare,7,8 the savings or losses of hospitals are adjusted according to their performance in a mix of hip- or knee-replacement quality measures such as rates of complications.
与其他捆绑式支付计划一样,5,6 CJR旨在为医院提供金钱激励,以便在住院期间和出院后的整个护理期间降低支出而不影响质量。在实施CJR期间,所有提供者(例如,门诊医师或专业护理机构)不必支付服务费。参与的医院进行年度回顾性调节,其中将每期的平均花费与医院特定的基准进行比较。 如果支出低于基准,医院将与医疗保险共享储蓄,或从2017年开始,如果支出超过目标1与2,医院将支付罚款。与医疗保险7和8中的问责护理组织计划类似,根据医院髋关节或膝关节置换质量测量表现,调整医院的储蓄或损失,如并发症的发生率。

Voluntary bundled-payment programs have been associated with either unchanged or reduced spending without deterioration in quality.9-11 However, changes observed in these programs could be due to the selective participation of highly motivated hospitals and providers.12,13  We also evaluated any potentially unintended consequences such as the selection of healthier patients for hip or knee replacement or an increased volume of these procedures.
自愿捆绑支付计划与未改变或减少的支出相关联而不会降低质量。然而,由于积极的医院和提供者的选择性参与,可以观察到这些计划的变化.我们还评估了任何可能出现的意料之外的后果,例如为髋关节或膝关节置换选择更健康的患者或增加手术的数量。


作者: Michael L. Barnett et al.M.D., Andrew Wilcock, Ph.D., J. Michael McWilliams, M.D.
期刊名:The New England Journal of Medicine.
发表时间:2019-01-02 DOI: 10.1056/NEJMsa1809010

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