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

项目摘要/摘要 急诊后护理(PAC)的医疗保险支付政策正在发生重大变化，这提供了 为需要医疗和康复(即，身体， 职业和语言治疗)服务成功地过渡回社区。熟练护理 设施(SNF)和家庭健康机构(HHA)占PAC支出的近80%。快速增长 PAC支出在很大程度上是由激励治疗服务的先前支付系统推动的。然而， 2019年10月对SNF实施了新的支付模式，2020年1月对HHA实施了新的支付模式，试图 解决(A)支出增长和(B)滥用治疗服务的可能性。这些新型号 取消对治疗的激励，但不包括对质量的控制(例如，社区出院、重新入院)。 对此，政府账目委员会的持份者提出关注，认为支付改革可能会对获取 对弱势群体(例如，具有双重资格、居住在农村的种族和族裔少数群体)的护理质量 和诊断亚组(例如痴呆症/阿尔茨海默氏症、髋部骨折)，因为改变了报销。而当 新模式旨在促进适当和高效的护理，支付改革的实际影响是 未知。我们假设SNF和HHA不会对更改的报销和 新的支付模式将对部分但不是所有患者的护理质量产生不利影响。 因此，我们的首要目标是评估支付改革对整体和弱势群体的影响。 群体和诊断亚群。使用自然的实验设计，充分利用 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方法 员工和患者，以及广泛的患者级别的联邦医疗保险索赔和评估数据，我们将： 目标1：通过量化治疗中的变化，确定SNF和HHA对支付改革的组织反应 人员编制和支付者混合后支付改革，并定性地探索利益相关者的观点 在新模式下提供高质量护理的组织流程、障碍和促进者。 目标2：表征出院后获得SNF和HHA的途径以及在以下方面的治疗利用 SNF/HHA预付后总体改革以及针对弱势群体和诊断分组的改革。 目标3：量化治疗利用和质量结果之间的联系(例如，功能改变) 全面和针对弱势群体和诊断亚群的预付费用改革。 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 激励高效护理的预期结果，以及(B)确定与以下方面有关的任何意外后果 在获得护理方面的差距和质量下降。调查结果将解决利益相关者的关切，并 向政策制定者、提供商、系统领导者和付款人提供有关支付影响的关键信息 改革患者准入和患者群体的质量，包括最脆弱的人群。

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.