Evaluating Pay for Performance and its Design: Evidence from Nursing Homes

改善超过4000万65岁以上美国人的护理质量是国家的主要优先事项，特别是随着人口老龄化。在过去的几十年里，虽然已经采取了许多政策来提高老年人的护理质量，但取得了不同程度的成功，医疗保健支付一直是一个基本上尚未开发的，但潜在的强大的政策工具，以提高护理质量。然而，最近，付款人已经投入了大量的资源，为医院，医生，疗养院和家庭健康提供者制定和实施按绩效付费计划。尽管人们对绩效工资的热情和广泛采用，但将此类计划与质量改进联系起来的经验证据却令人惊讶地薄弱。目前的证据留下了许多悬而未决的问题，不仅是绩效工资的有效性，但如何设计和实施这些计划影响质量改进。随着国家重点提高护理质量，修改当前的支付制度以奖励高质量护理将成为最重要的政策工具之一。为了提高这些政策的发展和成功，这是至关重要的，以获得更好地了解按业绩计薪的有效性和按业绩计薪计划的要素，最影响提供高质量的护理。本研究的总体目标是评估按绩效付费与养老院提供高质量护理之间的关系。几十年来，疗养院一直受到护理质量低下和未能大幅提高质量的困扰。这项拟议中的研究旨在利用迄今为止最大的按绩效付费的国家实验之一：最近一些州医疗补助机构采用了养老院按绩效付费。由于医疗补助的养老院按绩效付费计划是在州一级实施的，因此它们在计划设计和实施时间上各不相同。这为评价按业绩计薪及其设计提供了一个独特和及时的机会。使用国家数据对所有美国养老院从最低数据集，医疗保险索赔，和在线调查，认证和报告（OSCAR）数据库从1999年到2009年，本研究探讨了养老院护理质量的变化时，一些国家实施绩效工资，控制长期趋势的国家没有支付绩效。具体而言，本项目研究：1）按绩效付费是否通过改变临床质量指标、可避免的住院率、人员配备水平和缺陷数量来提高护理质量; 2）按绩效付费的设计如何影响护理质量的提高，研究每个项目中财务激励的大小和措施类型的差异;以及3）按业绩支付对设施之间护理差异的影响。这项研究的结果将有助于显着现有的文献按业绩计薪，并提供重要的信息，政策制定者和保险公司的设计和实施按业绩计薪。 公共卫生相关性：几十年来，疗养院一直受到护理质量低下和未能大幅提高质量的困扰。提高养老院的护理质量是国家的优先事项。该项目测试按绩效付费对养老院护理质量的影响，并将直接为未来提高养老院居民护理质量和设计更有效的按绩效付费计划提供信息。

DESCRIPTION (provided by applicant): Improving quality of care for the over 40 million Americans over the age of 65 is a major national priority, particularly as the population ages. While numerous policies have been adopted to improve quality of care for older adults over the past several decades-with varying degrees of success-health care payment has been a largely untapped but potentially powerful policy tool to improve quality of care. Recently, however, payers have invested significant resources in the development and implementation of pay-for-performance programs for hospitals, physicians, nursing homes, and home health providers. Despite the enthusiasm for and widespread adoption of pay for performance, the empirical evidence linking such programs to quality improvement is surprisingly thin. Current evidence leaves many unanswered questions concerning not only the effectiveness of pay-for-performance, but how the design and implementation of these programs affect quality improvement. As the country focuses on improving quality of care, modifying the current payment system to reward high-quality care will be one of the most important policy tools. To improve the development and success of these policies, it is crucial to gain a better understanding of the effectiveness of pay-for- performance and the elements of pay-for-performance programs that most influence provision of high-quality care. The overall objective of this study is to assess the relationship between pay-for-performance and the delivery of high-quality care in the setting of nursing homes. Nursing homes have been plagued for decades by low quality of care and failed attempts to substantially improve quality. The proposed study seeks to take advantage of one of the largest national experiments in pay-for-performance to date: the recent adoption of nursing home pay-for-performance by a number of state Medicaid agencies. Because Medicaid's nursing home pay-for-performance programs are implemented at a state level, they vary in program design and timing of implementation. This provides a unique and timely opportunity to evaluate pay-for-performance and its design. Using national data on all US nursing homes from the Minimum Data Set, Medicare claims, and the Online Survey, Certification, and Reporting (OSCAR) database from 1999 to 2009, this study examines changes in the quality of nursing home care when some states implemented pay for performance, controlling for secular trends in states without pay for performance. Specifically, this project examines: 1) whether pay- for-performance improves quality of care through changes in clinical quality measures, avoidable hospitalization rates, staffing levels, and number of deficiencies; 2) how the design of pay-for-performance affects improvement in quality of care, examining differences in the size of financial incentives and types of measures used in each program; and 3) the effect of pay-for-performance on disparities in care between facilities. The results from this study will contribute significantly to existing literature on pay-for-performance and provide vital information to policy makers and insurers regarding the design and implementation of pay-for- performance. PUBLIC HEALTH RELEVANCE: Nursing homes have been plagued for decades by low quality of care and failed attempts to substantially improve quality. Improving quality of care in nursing homes is a national priority. This project tests the effect of pay-for-performance on quality of care in nursing homes and will directly inform future efforts to improve quality of care for nursing home residents and design more effective pay-for-performance programs.