The effect of voluntary bundled payments on vulnerable populations

项目摘要 为了告知促进平等的支付政策，本研究探讨了自愿捆绑支付如何影响 少数种族、少数民族和社会经济地位低的个人的机会和结果 (SES)长期以来，弱势群体在获得医疗保健和成果方面面临着不平等。本申请 符合特别强调通知卫生服务研究优先事项，以实现高价值 医疗保健系统（NOT-HS-19-011）优先领域#3：成果支付。自愿捆绑付款 如果参与的提供者认为弱势患者的结果可能会加剧现有的差距， 难以管理和避免参与支付模型（即，提供商选择）或参与，但 避免照顾弱势群体（即，患者选择）。同样重要的是要了解如何影响 差异基于提供者的使命和照顾弱势群体的经验而变化（例如，安全网与 非安全网提供者）。这种见解对于下肢关节置换术（LEJR）尤其重要， 充血性心力衰竭（CHF）和败血症-最普遍的程序和条件，这两个 以显著的现有差异为特征，并以自愿捆绑支付计划为目标。的见解 考虑到COVID-19对支付改革和卫生的影响， 护理差异。我们假设，参与自愿捆绑支付计划的供应商将 与非参与者相比，不太可能位于弱势个人比例较高的市场; 与其他患者相比，弱势患者在获得和结果方面的差异将扩大， 与不参与的供应商相比，供应商开始参与自愿捆绑支付; 这些影响将因种族少数与少数民族地位以及种族和民族之间的相互作用而异。 少数民族地位和较低社会经济地位;与非安全网相比，安全网中差距扩大较小 提供商

Project Summary To inform payment policy that promotes parity, this study examines how voluntary bundled payments impact access and outcomes for racial minorities, ethnic minorities, and individuals with low socioeconomic status (SES), vulnerable groups that have long faced disparities in health care access and outcomes. This application aligns with the Special Emphasis Notice Health Services Research Priorities for Achieving a High Value Healthcare System (NOT-HS-19-011) Priority Area #3: Payment for outcomes. Voluntary bundled payments could exacerbate existing disparities if participating providers perceive that vulnerable patients’ outcomes are difficult to manage and avoid participating in the payment model (i.e., provider selection) or participate but avoid caring for vulnerable groups (i.e., patient selection). It is also vital to understand how impacts on disparities vary based on providers’ mission and experience caring for vulnerable groups (e.g., safety-net vs. non-safety-net providers). Such insights are particularly critical for lower extremity joint replacement (LEJR), congestive heart failure (CHF), and sepsis – the most prevalent procedures and conditions that are both marked by significant, existing disparities and targeted by voluntary bundled payment programs. The insights generated by this proposal are also critical given the impact of COVID-19 on both payment reform and health care disparities. We hypothesize that providers participating in voluntary bundled payment programs will be less likely than non-participants to be located in markets with a high proportion of vulnerable individuals; that disparities in access and outcomes will widen for vulnerable patients, as compared to other patients, after providers start participating in voluntary bundled payments compared to providers that do not participate; that these effects will vary by racial minority versus ethnic minority status, and interactions between racial and ethnic minority status and low SES; and that disparities will widen less at safety-net versus non-safety-net providers.