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Spending and quality after three years of Medicare's bundled payments for medical conditions: quasi-experimental difference-in-differences study.
The BMJ ( IF 105.7 ) Pub Date : 2020-06-17 , DOI: 10.1136/bmj.m1780
Joshua A Rolnick 1, 2, 3 , Joshua M Liao 4, 5 , Ezekiel J Emanuel 6 , Qian Huang 6 , Xinshuo Ma 6 , Eric Z Shan 6 , Claire Dinh 6 , Jingsan Zhu 6 , Erkuan Wang 6 , Deborah Cousins 6 , Amol S Navathe 5, 6, 7
Affiliation  

Objective To evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or health service use. Design Quasi-experimental difference-in-differences analysis. Setting US hospitals participating in bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and propensity score matched to non-participating hospitals. Participants 238 hospitals participating in the Bundled Payments for Care Improvement initiative (BPCI) and 1415 non-BPCI hospitals. 226 BPCI hospitals were matched to 700 non-BPCI hospitals. Main outcome measures Primary outcomes were total spending on episodes and death 90 days after discharge. Secondary outcomes included spending and use by type of post-acute care. BPCI and non-BPCI hospitals were compared by patient, hospital, and hospital market characteristics. Market characteristics included population size, competitiveness, and post-acute bed supply. Results In the 226 BPCI hospitals, episodes of care totaled 261 163 in the baseline period and 93 562 in the treatment period compared with 211 208 and 78 643 in the 700 matched non-BPCI hospitals, respectively, with small differences in hospital and market characteristics after matching. Differing trends were seen for some patient characteristics (eg, mean age change −0.3 years at BPCI hospitals v non- BPCI hospitals, P<0.001). In the adjusted analysis, participation in BPCI was associated with a decrease in total episode spending (−1.2%, 95% confidence interval −2.3% to −0.2%). Spending on care at skilled nursing facilities decreased (−6.3%, −10.0% to −2.5%) owing to a reduced number of facility days (−6.2%, −9.8% to −2.6%), and home health spending increased (4.4%, 1.4% to 7.5%). Mortality at 90 days did not change (−0.1 percentage points, 95% confidence interval −0.5 to 0.2 percentage points). Conclusions In this longer term evaluation of a large national programme on medical bundled payments in the US, participation in bundles for four common medical conditions was associated with savings at three years. The savings were generated by practice changes that decreased use of high intensity care after hospital discharge without affecting quality, which also suggests that bundles for medical conditions could require multiple years before changes in savings and practice emerge.

中文翻译:

联邦医疗保险(Medcare)对医疗条件捆绑付款三年后的支出和质量:准实验性差异研究。

目的评估长期参与美国医疗状况捆绑式付款计划(BPCI)的相关性,该计划使医院对从入院到出院后90天的护理期间的所有支出承担财务责任。支出,死亡率或医疗服务使用的变化。设计准实验差异分析。设置美国医院参加急性心肌梗塞,充血性心力衰竭,慢性阻塞性肺疾病(COPD)或肺炎的捆绑付款,其倾向评分与非参与医院一致。参与者238家医院参与了“改善护理费用捆绑支付计划”(BPCI),以及1415家非BPCI医院。226家BPCI医院与700家非BPCI医院匹配。主要结局指标主要结局指标是出院后90天的发作和死亡总支出。次要结果包括急性后护理类型的支出和使用。比较了BPCI和非BPCI医院的患者,医院和医院市场特征。市场特征包括人口规模,竞争力和急性病床供应。结果在226家BPCI医院中,基线期的护理总次数为261 163次,治疗期为93 562次,而在700家匹配的非BPCI医院中,分别为211 208名和78 643名,医院和市场特征差异很小匹配后。对于某些患者特征,趋势有所不同(例如,BPCI医院与非BPCI医院的平均年龄变化为-0.3岁,P <0.001)。在调整后的分析中,参与BPCI与发作总支出的减少相关(-1.2%,95%置信区间-2.3%至-0.2%)。由于减少的设施日数(-6.2%,-9.8%至-2.6%),以及熟练的家庭护理支出增加(4.4),熟练护理机构的护理支出减少了(-6.3%,-10.0%至-2.5%)。 %,1.4%至7.5%)。90天的死亡率没有变化(-0.1个百分点,95%的置信区间-0.5至0.2个百分点)。结论在对美国一项大型医疗捆绑支付国家计划的长期评估中,参加四种常见医疗条件的捆绑服务可节省三年的费用。节省是由于实践的改变而减少的,这些改变减少了出院后使用高强度护理而不影响质量,
更新日期:2020-06-17
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