Can the Medicare Quality Payment Program Incentivize Evidence-Based Treatment of Depression and Anxiety Disorders by Primary Care Providers?

项目摘要 抑郁症和焦虑症在初级保健环境中的患者中很常见，并且有明确的证据- 基于筛查、诊断和治疗的指南。然而，筛查和治疗的比率， 医疗保险受益人仍然很低。如果没有适当的治疗，这些患者可能会出现持续的 抑郁和焦虑症状，难以共同管理其他疾病，功能状态恶化，以及 可避免且昂贵的急性医疗事件。2017年，医疗保险推出了优质支付计划 (QPP)鼓励在门诊提供高质量、低成本、循证护理。初级 护理提供者（PCP）必须通过以下两种途径之一参与QPP：1）基于绩效的激励 支付系统（MIPS），默认轨道;或2）替代支付模式（APM），如责任关怀 以患者为中心的医疗之家（PCMH）。在APM和MIPS中，PCP 根据他们为患者提供的护理质量和成本，为他们的表现支付报酬。但 这些QPP模型对PCP治疗抑郁症和焦虑症的效果尚不清楚。有 迫切需要研究杀伤人员地雷和军事干预对获得护理和提供证据的影响， 基础治疗抑郁症和焦虑症在初级保健环境，以及随后的 患者的结果。我们的科学前提是，QPP，这是一个针对一般的计划， 患者人群，对抑郁症和焦虑症患者提供初级保健的动机相互冲突 紊乱一方面，QPP激励ACO和PCMH中的PCP采用创新的护理模式， 可能会提高循证治疗率。然而，另一方面，QPP并没有风险调整， 最常见的抑郁症和焦虑症类型，这对PCP产生了经济抑制作用， ACO和PCMH负责照顾患有这些疾病的患者，可能威胁到他们获得护理的机会。 这种负面后果可能在贫穷、属于种族和/或族裔的患者中进一步放大。 少数民族或居住在农村地区。本R 01申请的目的是进行纵向 研究将2017-2022年期间丰富的国家医疗保险索赔数据集、患者调查和PCP数据联系起来， 评价：1）将患者和PCP风险选择纳入APM与MIPS（目标1）; 2）是否有财务激励措施， QPP中的PCP有助于这种风险选择以及如何补救（目标2）;以及3） APM与MIPS中PCP对抑郁症循证治疗的患者护理， 焦虑症和随后的患者结局（目标#3）。我们假设，虽然患者 抑郁症和焦虑症将获得更高的循证治疗率， 当参与APM的PCP与MIPS进行治疗时，这些患者的结局仍然较少 可能由APM与MIPS中的PCP治疗的患者比没有这些条件的患者更少， 由于QPP中针对这些情况的风险调整不足而对其PCP造成的财务后果。

Project Summary Depression and anxiety disorders are common in patients in the primary care setting and have clear evidence- based guidelines for screening, diagnosis, and treatment. However, rates of screening and treatment among Medicare beneficiaries remain low. Without proper treatment, these patients may experience persistent depression and anxiety symptoms, difficulty co-managing other conditions, worsening functional status, and avoidable and expensive acute medical events. In 2017, Medicare launched the Quality Payment Program (QPP) to incentivize delivery of high quality, low cost, evidence-based care in the outpatient setting. Primary care providers (PCPs) are required to participate in the QPP via one of two tracks: 1) the Merit-Based Incentive Payment System (MIPS), the default track; or 2) alternative payment models (APMs) such as accountable care organizations (ACOs) and patient-centered medical homes (PCMHs). In the both the APMs and MIPS, PCPs are paid for their performance based on the quality and cost of care they deliver to patients. However, the effects of these QPP models on treatment of depression and anxiety disorders by PCPs are unknown. There is a critical need for research on the effects of the APMs and MIPS on access to care and delivery of evidence- based treatment for depression and anxiety disorders in the primary care setting, as well as subsequent outcomes for patients. Our scientific premise is that the QPP, which is a program targeted at the general patient population, has conflicting incentives for primary care delivery to patients with depression and anxiety disorders. On one hand, the QPP incentivizes PCPs in ACOs and PCMHs to adopt innovative care models that may increase rates of evidence-based treatment. However, on the other hand, the QPP does not risk adjust for the most prevalent types of depression and anxiety disorders, which creates a financial disincentive to PCPs in ACOs and PCMHs for caring for patients with these conditions, potentially threatening their access to care. This negative consequence may be further magnified among patients who are poor, belong to racial and/or ethnic minority groups, or live in rural areas. The objective of this R01 application is to conduct a longitudinal study linking rich national datasets of Medicare claims, patient surveys, and PCP data from 2017-2022 to evaluate: 1) patient and PCP risk selection into the APMs vs. MIPS (Aim #1); 2) whether financial incentives to PCPs in the QPP contribute to this risk selection and how they may be remedied (Aim #2); and 3) the effect of patient care from PCPs in the APMs vs. MIPS on delivery of evidence-based treatment for depression and anxiety disorders and subsequent patient outcomes (Aim #3). We hypothesize that although patients with depression and anxiety disorders will receive higher rates of evidence-based treatment and have better outcomes when treated by PCPs participating in the APMs vs. MIPS, these patients will nonetheless be less likely to be cared for by PCPs in the APMs vs. MIPS than patients without these conditions due to negative financial consequences to their PCPs caused by inadequate risk adjustment in the QPP for these conditions.