The impact of post acute care payment changes on access and outcomes

项目总结/摘要 医疗保险支付政策的实质性变化正在发生后急性护理（PAC），它提供了一个 为需要医疗和康复的个人提供从医院到家庭的桥梁（即，身体上的， 职业和言语治疗）服务，以成功地过渡到社区。专业护理 家庭保健机构（SNF）和家庭保健机构（HHA）占PAC支出的近80%。快速增长 PAC支出主要是由激励治疗服务的先前支付系统驱动的。然而，在这方面， 新的支付模式于2019年10月为SNF实施，2020年1月为HHA实施， 解决（a）支出增长和（B）滥用治疗服务的可能性。这些新模式 取消治疗激励措施，但不包括质量控制（例如，社区出院、再入院）。 作为回应，PAC利益相关者提出了支付改革可能会对获得 和对弱势群体的护理质量（例如，少数民族、双重资格、农村居民） 和诊断子组（例如，老年痴呆症/阿尔茨海默氏症，髋部骨折），由于不断变化的报销。而 新模式旨在促进适当和有效的护理，支付改革的实际影响是 未知我们假设SNF和HHA不会对不断变化的报销做出一致的反应， 新的支付模式将对一些但不是所有患者群体的护理质量产生不利影响。 因此，我们的总体目标是评估支付改革的总体影响和弱势群体的影响。 人群和诊断亚组。利用自然的实验设计， 支付改革和使用从SNF和HHA收集的丰富定性数据的混合方法 工作人员和患者，以及广泛的患者层面的医疗保险索赔和评估数据，我们将： 目标1：通过量化治疗变化，确定SNF和HHA组织对支付改革的反应 工作人员和付款人的组合，事后支付改革，并定性探讨利益相关者的观点， 组织流程、障碍和促进因素，以在新模式下提供高质量的护理。 目的2：描述出院后SNF和HHA的获取情况以及 SNF/HHA先付后付改革，包括对弱势群体和诊断分组的改革。 目标3：量化治疗利用与质量结局之间的关联（例如，职能变化） 全面的职前支付改革以及针对弱势群体和诊断分组的改革。 严格的定性和定量方法将使我们能够（a）评估支付改革是否 激励有效护理的预期结果，以及（B）识别与以下相关的任何非预期后果 在获得护理方面存在差距，质量受到影响。调查结果将解决利益攸关方的关切， 向政策制定者、供应商、系统领导者和付款人提供有关付款影响的关键信息 对包括最弱势群体在内的患者群体的患者获取和质量进行改革。

Project Summary/Abstract Substantial changes in Medicare payment policies are occurring for post-acute care (PAC), which provides a bridge from the hospital to home for individuals who require medical and rehabilitation (i.e., physical, occupational, and speech therapy) services to transition successfully back to the community. Skilled nursing facilities (SNFs) and home health agencies (HHAs) account for almost 80% of PAC spending. Rapid growth in PAC spending has been driven largely by prior payment systems that incentivized therapy services. However, new payment models were implemented in October 2019 for SNFs and January 2020 for HHAs that attempt to address (a) the growth in spending and (b) the potential for misuse of therapy services. These new models remove incentives for therapy but do not include controls for quality (e.g., community discharge, readmissions). In response, PAC stakeholders have raised concerns that payment reform may differentially impact access to and quality of care for vulnerable populations (e.g., racial and ethnic minorities, dually-eligible, rural-residing) and diagnostic subgroups (e.g., dementia/Alzheimer’s, hip fracture) due to changing reimbursements. While the new models are intended to promote appropriate and efficient care, the actual impact of payment reform is unknown. We hypothesize that SNFs and HHAs will not respond uniformly to changing reimbursements and that the new payment models will adversely impact quality of care for some, but not all, patient populations. Therefore, our overarching goal is to evaluate the impact of payment reform overall and among vulnerable populations and diagnostic subgroups. Using a natural experiment design that capitalizes on the timing of payment reform and a mixed methods approach that uses rich qualitative data collected from SNF and HHA staff and patients, as well as extensive patient-level Medicare claims and assessment data, we will: Aim 1: Identify SNF and HHA organizational responses to payment reform by quantifying changes in therapy staffing and payer mix pre-post payment reform and qualitatively exploring stakeholder perspectives on organizational processes, barriers, and facilitators to providing high-quality care under the new models. Aim 2: Characterize access to SNF and HHA after hospital discharge and utilization of therapy within SNF/HHA pre-post-payment reform overall and for vulnerable populations and diagnostic subgroups. Aim 3: Quantify the association between therapy utilization and quality outcomes (e.g., functional change) pre-post payment reform overall and for vulnerable populations and diagnostic subgroups. Rigorous qualitative and quantitative methodologies will allow us to (a) evaluate whether payment reform has the intended result of incentivizing efficient care and (b) identify any unintended consequences related to disparities in access to care and compromised quality. Findings will address stakeholders’ concerns and provide critical information to policymakers, providers, system leaders, and payers on the impact of payment reform on patient access and quality across patient populations, including the most vulnerable.