美国费城Crescenz VA医疗中心Amol S Navathe团队分析了医疗条件医保捆绑支付三年后的支出和质量。2020年6月17日出版的《英国医学杂志》发表了这项成果。

为了评估长期参与美国医疗条件捆绑护理支付计划（BPCI，使医院从入院到出院后90天的护理期间内对所有支出承担财务责任）是否与支出、死亡率或卫生服务使用的变化有关，研究组进行了一项准实验差异分析。

参与针对急性心肌梗塞、充血性心力衰竭、慢性阻塞性肺病（COPD）或肺炎的捆绑支付的美国医院，其倾向得分与非BPCI医院一致。238家医院参与了医疗服务改善捆绑支付计划（BPCI），1415家医院未参与。研究组将226家BPCI医院与700家非BPCI医院相匹配。主要结局是出院后90天疾病发作和死亡的总支出。

226所BPCI医院基线期的护理总次数为261163次，治疗期为93562次，而在700所匹配的非BPCI医院中，分别为211208次和78643次，匹配后医院和市场特征差异很小，但某些患者的特征差异较大。在校正后的分析中，参与BPCI减少了疾病发作的总支出。由于在护理机构中的住院天数减少了6.2%，熟练护理支出减少了6.3%，家庭医疗支出增加了4.4%。90天的死亡率没有显著变化。

总之，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在3年内可减少支出，出院后高强度护理有所减少，但质量未受影响。

附：英文原文

Title: Spending and quality after three years of Medicare’s bundled payments for medical conditions: quasi-experimental difference-in-differences study

Author: Joshua A Rolnick, Joshua M Liao, Ezekiel J Emanuel, Qian Huang, Xinshuo Ma, Eric Z Shan, Claire Dinh, Jingsan Zhu, Erkuan Wang, Deborah Cousins, Amol S Navathe

Issue&Volume: 2020/06/17

Abstract: 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 261163 in the baseline period and 93562 in the treatment period compared with 211208 and 78643 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.

DOI: 10.1136/bmj.m1780

Source: https://www.bmj.com/content/369/bmj.m1780