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期刊来源：JAMA

原文链接：https://doi.org/10.1001/jama.2024.2440

摘要内容如下：

重要性

医疗保险的医院价值采购（HVBP）计划将为医院提供健康公平调整（HEA），这些医院有更大比例的患者符合医疗保险和医疗补助的双重资格，并从2026财政年度开始提供高质量的护理。然而，哪些医院将从这一政策变化中受益最大，受益程度如何，都是未知数。

目的

估计HEA后医院绩效的潜在变化，并检查与收到增加的付款相关的医院患者组合、结构和地理特征。

设计、设置和参与者

该横断面研究分析了2021财年参与HVBP计划的所有2676家医院。将计划绩效和医院特征的公开可用数据与各医院双重资格受益人的所有住院医疗保险索赔数据相关联，以计算HEA积分和HVBP支付调整。

曝光

医院基于价值的采购计划。

主要成果和措施

HVBP奖金或罚款状态的重新分类以及不同医院特征的支付调整变化。

结果

在2021财年参与HVBP计划的2676家医院中，1470家（54.9%）获得了奖金，1206家（45.1%）受到了处罚。在HEA之后，102家医院（6.9%）从奖金状态重新分类为罚款状态，而119家医院（9.9%）从罚款状态重新分类为奖金状态。在医院层面，平均（SD）HVBP支付调整在HEA后减少了$4534（$90033），范围从最大减少$1014276到最大增加$1523765。总体而言，在安全网医院（28971708美元）和照顾黑人患者比例较高的医院（15468445美元）中，支付调整的净正变化最大。与非安全网医院相比，安全网医院的支付调整增加的可能性明显更高（683家医院中的574家[84.0%]比1993年的709家[35.6%]；校正比率[ARR]，2.04[95%CI，1.89-2.20]）和高比例黑人医院与非高比例黑人医院相比（523家医院中的396家[75.7%]vs 2153家医院中的887家[41.2%]；ARR，1.40[95%CI，1.29-1.51]）。农村医院（612所医院中的374所[61.1%]和2064所医院中的909所[44.0%]）；ARR，1.44[95%CI，1.30-1.58]），以及位于南部的患者（1040例中的598例[57.5%]vs 439例中的192例[43.7%]；ARR，1.25[95%CI，1.10-1.42]）和医疗补助扩展州（1651人中的801人[48.5%]vs 1025人中的482人[47.0%]；ARR，1.16[95%CI，1.06-1.28]），也更有可能在HEA后经历更多的支付调整，分别与城市、东北部和Medicaid非扩展州的同行相比。

结论和相关性

Medicare在HVBP计划中实施HEA将显著重新分类医院绩效并重新分配计划付款，安全网和高比例黑人医院将从这一政策变化中获益最多。这些发现表明，HEA是确保基于价值的支付计划更加公平的重要策略。

英文原文如下：

Abstracts

Importance  Medicare's Hospital Value-Based Purchasing (HVBP) program will provide a health equity adjustment (HEA) to hospitals that have greater proportions of patients dually eligible for Medicare and Medicaid and that offer high-quality care beginning in fiscal year 2026. However, which hospitals will benefit most from this policy change and to what extent are unknown.

Objective  To estimate potential changes in hospital performance after HEA and examine hospital patient mix, structural, and geographic characteristics associated with receipt of increased payments.

Design, Setting, and Participants  This cross-sectional study analyzed all 2676 hospitals participating in the HVBP program in fiscal year 2021. Publicly available data on program performance and hospital characteristics were linked to Medicare claims data on all inpatient stays for dual-eligible beneficiaries at each hospital to calculate HEA points and HVBP payment adjustments.

Exposures  Hospital Value-Based Purchasing program HEA.

Main Outcomes and Measures  Reclassification of HVBP bonus or penalty status and changes in payment adjustments across hospital characteristics.

Results  Of 2676 hospitals participating in the HVBP program in fiscal year 2021, 1470 (54.9%) received bonuses and 1206 (45.1%) received penalties. After HEA, 102 hospitals (6.9%) were reclassified from bonus to penalty status, whereas 119 (9.9%) were reclassified from penalty to bonus status. At the hospital level, mean (SD) HVBP payment adjustments decreased by $4534 ($90 033) after HEA, ranging from a maximum reduction of $1 014 276 to a maximum increase of $1 523 765. At the aggregate level, net-positive changes in payment adjustments were largest among safety net hospitals ($28 971 708) and those caring for a higher proportion of Black patients ($15 468 445). The likelihood of experiencing increases in payment adjustments was significantly higher among safety net compared with non-safety net hospitals (574 of 683 [84.0%] vs 709 of 1993 [35.6%]; adjusted rate ratio [ARR], 2.04 [95% CI, 1.89-2.20]) and high-proportion Black hospitals compared with non-high-proportion Black hospitals (396 of 523 [75.7%] vs 887 of 2153 [41.2%]; ARR, 1.40 [95% CI, 1.29-1.51]). Rural hospitals (374 of 612 [61.1%] vs 909 of 2064 [44.0%]; ARR, 1.44 [95% CI, 1.30-1.58]), as well as those located in the South (598 of 1040 [57.5%] vs 192 of 439 [43.7%]; ARR, 1.25 [95% CI, 1.10-1.42]) and in Medicaid expansion states (801 of 1651 [48.5%] vs 482 of 1025 [47.0%]; ARR, 1.16 [95% CI, 1.06-1.28]), were also more likely to experience increased payment adjustments after HEA compared with their urban, Northeastern, and Medicaid nonexpansion state counterparts, respectively.

Conclusions and Relevance  Medicare's implementation of HEA in the HVBP program will significantly reclassify hospital performance and redistribute program payments, with safety net and high-proportion Black hospitals benefiting most from this policy change. These findings suggest that HEA is an important strategy to ensure that value-based payment programs are more equitable.

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