捆绑付款的目标——一次性货币金额,旨在支付为疾病或医疗事件提供护理所需的全套服务——是提供一种激励患者价值提高的报销结构。人们担心这种支付机制可能会导致患者筛查,并根据与手术后并发症相关的合并症的数量和严重程度,拒绝或向患者提供骨科护理。目前,然而,对于这种协会是否存在,没有明确的共识。
在这篇系统综述中,我们问:(1)捆绑支付模式的实施是否与接受骨科手术的患者的社会人口统计学特征的变化有关?(2)捆绑支付模式的实施是否与接受骨科手术的患者的合并症和/或病例复杂性特征的变化有关?我们的系统综述包括发表在MEDLINE上的科学手稿,Embase,WebofScience,Econlit,Policyfile,和谷歌学者到2020年3月。在进行全文回顾的30项研究中,20人被排除在外,因为他们没有评估感兴趣的结果(患者选择)(n=8);是社论,评注,或审查文章(n=5);没有评估适当的干预措施(引入捆绑支付计划)(n=4);或评估错误的患者人群(非骨科手术患者)(n=3)。这导致了10项研究纳入本系统综述。对于每一项研究,纳入研究中分析的患者因素分为以下三类:社会人口统计学,合并症和/或病例复杂性,或最近使用医疗保健资源的特点。接下来,我们对属于这三类之一的每个患者因素进行了检查,以评估捆绑支付计划实施前后的变化.在大多数情况下,研究使用差异(DID)统计技术来评估变化。还注意到确定捆绑支付倡议是否需要强制参与。使用适应的纽卡斯尔-渥太华量表的科学质量的中位数(范围)得分为8(7至8;最高得分:9),使用建议分级,发现每个患者特征组的总体证据质量较低,评估,开发和评估(等级)工具。我们无法使用漏斗图评估发表的可能性,因为在每项研究中分析的患者因素存在差异,并且数据的异质性排除了荟萃分析。
在九项纳入的研究中,这些研究报告了选择接受护理的患者的社会人口统计学特征,七个显示随着捆绑支付的实施没有变化,两个人表现出了不同。最值得注意的是,研究发现接受骨科手术干预的患者中双重合格的百分比下降(范围DID估计值-0.4%[95%CI-0.75%至-0.1%];p<0.05至DID估计值-1.0%[95%CI-1.7%至-0.2%];p=0.01),这意味着他们有资格获得医疗保险和医疗补助保险。在报告合并症和病例复杂性特征的10项纳入研究中,六个报告说,随着捆绑支付的实施,这种特征没有变化,四项研究指出了差异。最值得注意的是,一项研究表明,与捆绑支付实施前相比,接受治疗的残疾患者数量有所减少(DID估计值-0.6%[95%CI-0.97%至-0.18%];p<0.05),而另一个人显示,对于那些被视为捆绑支付计划一部分的人来说,Elixhauser合并症的数量较低(之前:63.6%的得分为0-1,27.9%中的2-3,>3在8.5%与之后:50.1%的0-1得分,38.7%中的2-3,11.2%中>3;p=0.033)。在三项纳入的研究中,报告了患者最近使用医疗保健资源的情况,一项研究发现,医疗资源的使用与捆绑支付的实施没有差异,两项研究确实发现了差异。两项研究均发现,最近在熟练护理机构接受护理的接受手术管理的患者有所减少(范围DID估计值-0.50%[95%CI-1.0%至0.0%];p=0.04至DID估计值:-0.53%[95%CI-0.96%至-0.10%];p=0.01),而其中一项研究还发现,接受手术管理的患者最近在一家急症护理医院接受护理(DID估计值-0.8%[95%CI-1.6%~-0.1%];p=0.03)或作为家庭医疗保健的一部分(DID估计值-1.3%[95%CI-2.0%~-0.6%];p<0.001)有所减少.
在10项研究中的6项研究中,在启动捆绑支付计划后,在接受骨科手术干预的患者中发现了患者特征的差异,发现效果很小(约1%或更低).然而,我们的发现仍然表明了一定程度的不良患者选择,如果大规模考虑,可能会加剧健康不平等。我们的发现也有可能反映出更好的护理,因此,经济激励措施可减少接受手术干预的并发症风险高的患者,反之亦然,术后并发症风险低的患者。然而,这是一条细线,也可能是术后并发症风险高的患者没有得到足够的手术,而术后并发症风险低的患者接受手术的频率过高。有必要评估这些初步捆绑支付计划对患者选择的长期影响,以确定随着卫生系统和整形外科医生习惯于这种报销模式,不良患者选择是否会随着时间的推移而改变。
The goal of bundled payments-lump monetary sums designed to cover the full set of services needed to provide care for a condition or medical event-is to provide a reimbursement structure that incentivizes improved value for patients. There is concern that such a payment mechanism may lead to patient screening and denying or providing orthopaedic care to patients based on the number and severity of comorbid conditions present associated with complications after surgery. Currently, however, there is no clear consensus about whether such an association exists.
In this systematic
review, we asked: (1) Is the implementation of a bundled payment model associated with a change in the sociodemographic characteristics of patients undergoing an orthopaedic procedure? (2) Is the implementation of a bundled payment model associated with a change in the comorbidities and/or case-complexity characteristics of patients undergoing an orthopaedic procedure? (3) Is the implementation of a bundled payment model associated with a change in the recent use of healthcare resources characteristics of patients undergoing an orthopaedic procedure?
This systematic
review was registered in PROSPERO before data collection (CRD42020189416). Our systematic review included scientific manuscripts published in MEDLINE, Embase, Web of Science, Econlit, Policyfile, and Google Scholar through March 2020. Of the 30 studies undergoing full-text
review, 20 were excluded because they did not evaluate the outcome of interest (patient selection) (n = 8); were editorial, commentary, or
review articles (n = 5); did not evaluate the appropriate intervention (introduction of a bundled payment program) (n = 4); or assessed the wrong patient population (not orthopaedic surgery patients) (n = 3). This led to 10 studies included in this systematic
review. For each study, patient factors analyzed in the included studies were grouped into the following three categories: sociodemographics, comorbidities and/or case complexity, or recent use of healthcare resources characteristics. Next, each patient factor falling into one of these three categories was examined to evaluate for changes from before to after implementation of a bundled payment initiative. In most cases, studies utilized a difference-in-difference (DID) statistical technique to assess for changes. Determination of whether the bundled payment initiative required mandatory participation or not was also noted. Scientific quality using the Adapted Newcastle-Ottawa Scale had a median (range) score of 8 (7 to 8; highest possible score: 9), and the quality of the total body of evidence for each patient characteristic group was found to be low using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) tool. We could not assess the likelihood of publication using funnel plots because of the variation of patient factors analyzed in each study and the heterogeneity of data precluded a meta-analysis.
Of the nine included studies that reported on the sociodemographic characteristics of patients selected for care, seven showed no change with the implementation of bundled payments, and two demonstrated a difference. Most notably, the studies identified a decrease in the percentage of patients undergoing an orthopaedic operative intervention who were dual-eligible (range DID estimate -0.4% [95% CI -0.75% to -0.1%]; p < 0.05 to DID estimate -1.0% [95% CI -1.7% to -0.2%]; p = 0.01), which means they qualified for both Medicare and Medicaid insurance coverage. Of the 10 included studies that reported on comorbidities and case-complexity characteristics, six reported no change in such characteristics with the implementation of bundled payments, and four studies noted differences. Most notably, one study showed a decrease in the number of treated patients with disabilities (DID estimate -0.6% [95% CI -0.97% to -0.18%]; p < 0.05) compared with before bundled payment implementation, while another demonstrated a lower number of Elixhauser comorbidities for those treated as part of a bundled payment program (before: score of 0-1 in 63.6%, 2-3 in 27.9%, > 3 in 8.5% versus after: score of 0-1 in 50.1%, 2-3 in 38.7%, > 3 in 11.2%; p = 0.033). Of the three included studies that reported on the recent use of healthcare resources of patients, one study found no difference in the use of healthcare resources with the implementation of bundled payments, and two studies did find differences. Both studies found a decrease in patients undergoing operative management who recently received care at a skilled nursing facility (range DID estimate -0.50% [95% CI -1.0% to 0.0%]; p = 0.04 to DID estimate: -0.53% [95% CI -0.96% to -0.10%]; p = 0.01), while one of the studies also found a decrease in patients undergoing operative management who recently received care at an acute care hospital (DID estimate -0.8% [95% CI -1.6% to -0.1%]; p = 0.03) or as part of home healthcare (DID estimate -1.3% [95% CI -2.0% to -0.6%]; p < 0.001).
In six of 10 studies in which differences in patient characteristics were detected among those undergoing operative orthopaedic intervention once a bundled payment program was initiated, the effect was found to be minimal (approximately 1% or less). However, our findings still suggest some level of adverse patient selection, potentially worsening health inequities when considered on a large scale. It is also possible that our findings reflect better care, whereby the financial incentives lead to fewer patients with a high risk of complications undergoing surgical intervention and vice versa for patients with a low risk of complications postoperatively. However, this is a fine line, and it may also be that patients with a high risk of complications postoperatively are not being offered surgery enough, while patients at low risk of complications postoperatively are being offered surgery too frequently. Evaluation of the longer-term effect of these preliminary bundled payment programs on patient selection is warranted to determine whether adverse patient selection changes over time as health systems and orthopaedic surgeons become accustomed to such reimbursement models.