Impact of Bundled Payment Reforms on Racial and Socioeconomic Disparities in Hip and Knee Replacement Surgeries

捆绑支付改革对髋关节和膝关节置换手术中种族和社会经济差异的影响

基本信息

批准号：
9468901
负责人：
Caroline Pinto Thirukumaran
金额：
$ 38.5万
依托单位：
UNIVERSITY OF ROCHESTER
依托单位国家：
美国
项目类别：
财政年份：
2017
资助国家：
美国
起止时间：
2017-09-20 至 2021-04-30
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/9468901
关键词：
Acute Address Adopted Area Behavior Benchmarking Caring Categories Clinical Comprehensive Health Care Data Degenerative polyarthritis Effectiveness Elderly Expenditure Face Future Goals Growth Healthcare Healthcare Systems Home environment Hospitals Incentives Inpatients Investments Knowledge Length Length of Stay Light Literature Lower Extremity Measures Mediating Medicare Minority Minority Groups Modeling Operative Surgical Procedures Outcome Patient Care Patient Discharge Patients Performance Policies Policy Maker Population Race Rehabilitation therapy Replacement Arthroplasty Resources Rewards Risk Social support Testing United States Centers for Medicare and Medicaid Services beneficiary care episode cost design disparity reduction dual eligible effective therapy evidence base experience financial incentive health care delivery health care disparity hip replacement arthroplasty improved improved outcome individual patient knee replacement arthroplasty knowledge base longitudinal analysis metropolitan payment prevent programs racial disparity racial minority response safety net socioeconomic disparity socioeconomics

项目摘要

Project Abstract: Hip and knee replacement surgeries for elderly Medicare beneficiaries have important clinical implications given their effectiveness for advanced osteoarthritis; and important financial implications given their high volume, expenditure, and expected growth in demand. Racial and socioeconomic disparities in the care of these surgeries are well-documented. Our preliminary analysis and other studies have demonstrated that blacks undergo these surgeries less frequently and have poorer outcomes as compared to whites, and that patients from lower socioeconomic strata face greater barriers than those from the upper socioeconomic strata in their access to these surgeries. In 2016, the Centers for Medicare and Medicaid Services introduced the Comprehensive Care for Joint Replacement (CJR) Model, which is a bundled payment reform that bundles/includes most spending related to these surgeries (beginning with the inpatient stay, continuing to post-acute care, and ending 90 days after discharge from the hospital) under a single surgical episode. Hospitals, clinicians and post-acute care facilities are therefore financially incentivized to improve the coordination of care across settings, to keep their spending low and to meet important quality benchmarks. However, experts have raised concerns that in the absence of metrics aimed at reducing disparities, the design of the CJR is likely to exacerbate disparities in hip and knee replacement care across patients of different racial and socioeconomic categories, and across hospitals that serve varying proportions of minority patients. These concerns have considerable face validity, yet the impact of bundled payments in general, and the CJR in particular, on disparities has not been empirically evaluated. In light of these gaps in empirical literature, the aims of our proposal are to evaluate the impact of the CJR on racial and socioeconomic disparities in utilization (Aim 1), inpatient outcomes (Aim 2), and post-acute care outcomes (Aim 3) of hip and knee replacement care. Furthermore, we will identify key mechanisms that influence CJR's impact on disparities, and investigate if the changes in outcomes and disparities that we expect are mediated by the choice of post-acute care facility to which a patient is discharged (Aim 4). The overarching rationale for these aims is that in pursuit of financial rewards from the CJR, hospitals are likely to avoid sicker patients, many of whom are likely to be racial and socioeconomic minorities; and hospitals, clinicians, and post-acute care facilities will adopt cost-reduction strategies that may target and adversely influence minority patients, thereby exacerbating disparities. We will conduct rigorous longitudinal analyses using national data to address the specific aims and test associated hypotheses. The knowledge gained from our study will inform the design of current and future bundled payment reforms such that these reforms can prevent the exacerbation of and contribute in reducing existing racial and socioeconomic disparities in hip and knee replacement surgeries."

项目摘要：老年医疗保险受益人的髋关节和膝关节置换手术具有重要的临床意义鉴于其对晚期骨关节炎的有效性；以及鉴于其高的财务影响数量、支出和预期需求增长。照顾者方面的种族和社会经济差异这些手术都有详细记录。我们的初步分析和其他研究表明与白人相比，黑人接受这些手术的频率较低，结果也较差来自较低社会经济阶层的患者比来自较高社会经济阶层的患者面临更大的障碍他们接受这些手术的机会。 2016 年，医疗保险和医疗补助服务中心推出了关节置换综合护理（CJR）模式，这是一项捆绑支付改革，捆绑/包括与这些手术相关的大部分支出（从住院开始，继续到急性后护理，并在出院后 90 天结束）在一次手术中。因此，医院、临床医生和急症后护理机构会受到经济激励来改善协调跨环境的护理，以保持较低的支出并满足重要的质量基准。然而，专家们担心，在缺乏旨在减少差距的指标的情况下，设计 CJR 的实施可能会加剧不同种族患者在髋关节和膝关节置换护理方面的差异和社会经济类别，以及为不同比例的少数族裔患者提供服务的医院。这些担忧具有相当大的表面有效性，但捆绑支付的总体影响以及 CJR 在特别是，尚未对差异进行实证评估。鉴于实证文献中的这些空白，我们提案的目的是评估 CJR 对利用方面的种族和社会经济差异的影响髋关节和膝关节置换护理的（目标 1）、住院结果（目标 2）和急性后护理结果（目标 3）。此外，我们将确定影响 CJR 对差异影响的关键机制，并调查是否我们预期的结果和差异的变化是通过选择急性后护理机构来调节的患者出院（目标 4）。这些目标的总体理由是为了追求财务由于 CJR 的奖励，医院可能会避免病情较重的患者，其中许多人可能是种族和社会经济少数群体；医院、临床医生和急症后护理机构将采取降低成本的措施可能针对少数群体患者并对少数群体患者产生不利影响的策略，从而加剧差异。我们将使用国家数据进行严格的纵向分析，以解决具体目标并测试相关假设。从我们的研究中获得的知识将为当前和未来捆绑的设计提供信息支付改革，以便这些改革可以防止恶化并有助于减少现有的髋关节和膝关节置换手术中的种族和社会经济差异。”