美國包裹式支付照護改善計畫之發展

Development of bundled payment initiatives for care improvement in the United States

美國聯邦醫療保險和聯邦醫療補助計劃服務中心（Centers for Medicare & Medicaid Services, CMS）自2013年至2018年實施全國性包裹式支付照護改善計畫（Bundled Payments for Care Improvement, BPCI），將急性住院或處置與急性後期照護（post-acute care, PAC）服務包裹於一筆前瞻性定額支付，發展四種模式，包括模式一（急性住院）、模式二（急性住院加PAC加再住院）、模式三（PAC加再住院）、模式四（急性住院加再住院），朝向以價值為基礎的照護（value-based care），在維持同等照護品質下，降低醫療費用支出。BPCI初始版計畫實施後，病程照護醫療費用支出有減少，但因支付調整（reconciliation）僅分享節餘（shared savings），未執行分擔成本（shared costs），致Medicare虧損；因此2018年至2025年改採BPCI進階版（BPCI Advanced）計畫，BPCI進階版僅保留BPCI初始版中的模式2，該模式是BPCI初始版實施期間，參與單位最多且費用控制最好之模式，且不再計算出院後30日與出院後60日，僅採包裹出院後90日；亦即進階版的模式是包括當次急性住院以及出院日起90天內之PAC與再住院；且目標價之訂定亦納入多項醫院實際照護後之因素，並將照護品質指標作為支付調整之參考；BPCI進階版實施後，至2020年進行的評估，發現可維持照護品質且讓醫療費用支出上升逐漸趨緩。為因應我國快速高齡少子化與醫療費用逐年上升，建議政府可借鏡美國包裹式支付制度的經驗，參考美國挑選的BPCI項目，針對需要PAC的個案，將住院和處置與PAC及長照2.0復能之服務包裹於定額支付，輔以照護品質監測機制，以提供患者連續性與高品質的照護。

In 2013, the US Centers for Medicare and Medicaid Services implemented the nationwide Bundled Payments for Care Improvement (BPCI) initiative. The BPCI initiative comprised four case models, namely Model 1, Acute Care Hospital Stay Only; Model 2, Acute & Post-Acute Care Episode; Model 3, Post-Acute Care Only; and Model 4, Prospective Acute Care Hospital Stay Only. The goal of the BPCI initiative was to transition from a traditional fee-for-service model to value-based care through bundling acute inpatient or outpatient procedures with post acute care (PAC) services into a single prospective payment, reducing health-care expenditures while maintaining quality of care. This initiative successfully reduced payments for discrete care episodes but incurred net losses due to the cancellation of shared costs, despite the presence of shared savings in payment reconciliation. Therefore, in 2018, the BPCI Advanced program was initiated as a continuation of the BCPI Model 2, which had the most participants and the best cost control. The BCPI program focused solely on bundling services from the time of an inpatient or outpatient procedure to 90 days after discharge. Additionally, the program incorporated the individual composite quality score of each participant into adjustments to target pricing methodology and payment reconciliation to slow the rise in health-care expenditures while maintaining quality of care. Given increasing health-care costs in Taiwan (due to a rapidly aging population and declining birth rate), the government should consider implementing a prospective payment program for hospitalization and PAC. Acute care can also be bundled with PAC and rehabilitation services under the Long-Term Care Plan 2.0 into fixed payments. This program should monitor care quality indicators to reduce national health expenditures while maintaining high-quality care for patients.