Evaluating the Effects of CMS' Prospective Episode-Based "Bundling" Payment Model for Lower Limb Joint Replacement: Post-acute Care Setting, Costs and Patient Outcomes

评估 CMS 基于前瞻性事件的“捆绑”支付模式对下肢关节置换的效果：急性后护理环境、成本和患者结果

• 批准号: 9982744
• 负责人: TIMOTHY R DILLINGHAM
• 金额: $ 23.41万
• 依托单位: UNIVERSITY OF PENNSYLVANIA
• 依托单位国家: 美国
• 财政年份: 2018
• 资助国家: 美国
• 起止时间: 2018-09-15 至 2022-05-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9982744
• 关键词: Acute; Amputation; Area; Budgets; Bundling; Caring; Clinical; Comprehensive Health Care; Control Groups; Cost Savings; Cost Sharing; Destinations; Effectiveness; Elderly; Environment; Eye; Geographic Locations; Geography; Goals; Government; Growth; Health Care Reform; Hip Fractures; Hip region structure; Home Care Services; Home Health Agency; Incentives; Inpatients; Insurance; Insurance Carriers; Knee; Lead; Length of Stay; Lower Extremity; Medical; Medical Care Costs; Medical Geography; Medicare; Modeling; Musculoskeletal; Natural experiment; Neurologic; Outcome; Patient-Focused Outcomes; Patients; Pattern; Persons; Policies; Policy Maker; Provider; Quality of Care; Rehabilitation therapy; Replacement Arthroplasty; Research Personnel; Risk; Services; Skilled Nursing Facilities; Stroke; System; Techniques; Time; Time trend; Uncertainty; United States Centers for Medicare and Medicaid Services; Variant; acute care; adverse outcome; base; beneficiary; bundled payment; care costs; care episode; care outcomes; care systems; cohort; comparison group; cost; cost outcomes; experience; hip replacement arthroplasty; hospital readmission; improved; interest; knee replacement arthroplasty; mortality; novel strategies; payment; programs; prospective; rehabilitation service; rehabilitative care; social

Prompted by the growth in Medicare spending and uncertainty about the effectiveness of post-acute care provided at alternative settings (e.g., inpatient rehabilitation facilities, skilled nursing facilities, home health agencies), the Center for Medicare and Medicaid Services (CMS) has established a mandatory, episode- based, prospective bundling payment model for persons undergoing elective joint arthroplasties, implemented as part of its Comprehensive Care for Joint Replacement (CJR) Rule of 2016. Bundles are based on inpatient DRGs and include all relevant Medicare costs during an episode-of-care, defined as the inpatient stay and 90 days post-acute discharge, regardless of post-acute care setting. In this application, we take advantage of the natural experiment afforded by CMS’ regional variation in implementation of the CJR Rule to examine the impact of bundling on service use, outcomes, and cost of care for the approximately 400,000 Medicare beneficiaries undergoing joint replacements every year. Specifically, our aims are: 1. To examine the effect of bundling on acute care length-of-stay, post-acute care discharge setting, and 90-day medical care costs among beneficiaries undergoing total knee (TKA) or hip (THA) arthroplasty, conditions targeted for bundled payments; 2. To estimate the effect of bundling on clinical and utilization outcomes at 12-months post-acute care discharge among patients with targeted conditions, and to quantify potential spillover effects on care and outcomes of patients with non-targeted musculoskeletal (hip fractures, amputations) and neurological (stroke) conditions; and 3. To estimate the impact of bundling on the value of care provided to patients with targeted and non-targeted conditions, and to discuss the implications of these relationships for post-acute care policy and program initiatives. Using difference-in-difference-in-difference techniques, we will estimate the effect of bundling on 12-month outcomes, including complications, medical (in)stability, re-hospitalizations, and mortality. Analyses conducted with serial cohorts of patients with non-targeted conditions will provide additional comparison groups and enable us to estimate possible spillover effects of the CJR Rule. Results from this study will provide important “real time” information for all interested in the challenges of providing effective post-acute care to the large and growing number of elderly persons requiring rehabilitation, including government, policy-makers, payers, and consumers. The findings will also be relevant in the current ACA- replace and repeal environment, which is expected to further reduce access to and reimbursement for these and other post-acute care services.

受到医疗保险支出的增长和急性护理有效性的不确定性的提示 在替代设置（例如，住院康复设施，熟练的护士设施，家庭健康 代理商），医疗保险和医疗补助服务中心（CMS）已建立了一个强制性的一集 - 实施的基于选修联合关节塑料的人的基于的，潜在的捆绑付款模型 作为其2016年联合置换综合护理（CJR）规则的一部分。捆绑包基于住院 DRG，包括所有相关的Medicare费用，在保健情节中，定义为住院住宿和90 急性出院后的天数，无论急性后护理设置如何。在此应用中，我们利用 CMS在CJR规则实施方面的区域差异提供的自然实验以检查 捆绑的影响对大约40万Medicare的服务使用，结果和护理成本的影响 受益人每年接受联合替代者。具体来说，我们的目标是：1。检查 捆绑在急性护理期间，急性护理后出院设置和90天的医疗费用 在接受总膝盖（TKA）或髋关节置换术的受益人中，针对捆绑的条件 付款； 2。估计捆绑对急性12个月临床和利用结果的影响 有针对性疾病的患者之间的护理出院，并量化潜在的对护理和护理的影响 非靶向肌肉骨骼（髋部骨折，截肢）和神经系统（中风）的患者的结局 状况;和3。估计捆绑包对提供针对性患者提供的护理价值的影响 和非目标条件，并讨论这些关系对急性后护理政策的影响 和计划计划。使用差异差异差异技术的差异，我们将估计 捆绑12个月的结果，包括并发症，稳定性，重新住院以及 死亡。用具有非靶向条件的患者进行的分析将提供额外 比较组，使我们能够估算CJR规则的敏捷效应。结果 研究将为所有有趣的挑战提供重要的“实时”信息 急性后照顾需要康复的大量老年人，包括 政府，政策制定者，付款人和消费者。这些发现也将与当前的ACA-相关 替换和废除环境，预计将进一步减少对这些环境的访问和报销 和其他急性后护理服务。