The impact of population and episode-based payment models on surgical disparities

项目摘要 作为全国范围内转向基于价值的支付的杰出领导者，联邦医疗保险实施了大量 支持组织的按服务收费、基于人口和事件的替代支付模式(APM) 在财务上对护理的质量和成本负责。然而，这些APM的设计不是为了保护 种族/族裔少数群体和社会经济地位较低的个人的机会或结果。这些 与其他个人相比，弱势群体已经面临着巨大的外科差异。这些差距 如果参与的提供商参与患者选择，则在这两种APM类型下可能会进一步恶化 易受伤害的患者在参与后获得外科手术或改变其护理。因为 政策制定者必须就如何利用不同的反兴奋剂机制来推动全国范围内的改革做出关键决定， 洞察基于人群和事件的急性呼吸综合征如何影响脆弱患者的手术差异 帮助政策制定者确定如何以最佳方式设计、细化、实施政策调整，并以不同方式扩大规模 保障弱势患者护理的典范。这项研究调查了医疗保险费用如何突出- 与外科护理高度相关的服务人群和基于事件的急性呼吸综合征会影响 弱势患者的手术途径和结果，跨保险覆盖类型，以及是否有效果 因提供商与APM奖励相关的财务属性而异。我们假设APM的参与将是 与手术机会和结果(质量、利用率和成本)方面的差距扩大有关 在提供者开始参与APM后，易受攻击的患者与非易受攻击的患者。我们还假设 对手术差异的影响将因提供者的财务属性而有所不同-财务风险和 支付者组合-与APM激励相关。

Project Summary As a prominent leader in the nationwide shift towards value-based payment, Medicare has implemented large fee-for-service population- and episode-based alternative payment models (APMs) that hold organizations financially accountable for the quality and costs of care. However, these APMs are not designed to protect access or outcomes for racial/ethnic minorities and individuals with low socioeconomic status. These vulnerable groups already face significant surgical disparities compared to other individuals. These disparities could worsen further under both APM types if participating providers engage in patient selection that reduces vulnerable patients’ access to surgical procedures or changes their care after participating. Because policymakers must make critical decisions about how to use different APMs to catalyze nationwide reform, insight about how population- and episode-based APMs affect surgical disparities for vulnerable patients can help policymakers determine how to best design, refine, implement policy adjustments, and scale up different models to safeguard the care of vulnerable patients. This study examines how prominent Medicare fee-for- service population- and episode-based APMs that are highly relevant to surgical care affect disparities in surgical access and outcomes for vulnerable patients, across insurance coverage type, and whether effects vary by providers’ financial attributes related to APM incentives. We hypothesize that APM participation will be associated with widened disparities in surgical access and outcomes (quality, utilization, and cost) for vulnerable vs. non-vulnerable patients after providers begin participating in APMs. We also hypothesize that the impact on surgical disparities will vary by providers’ financial attributes – experience with financial risk and payer mix – related to APM incentives.