Screening for Free: A Value-Based Insurance Design Natural Experiment

描述（由申请人提供）：将健康保险福利与临床目标相结合，即基于价值的保险设计（VBID），对于减少推荐护理的财务障碍，提高质量和调节支出增长有很大的希望。虽然研究发现，患者费用分摊可以减少必要护理的使用，并增加下游护理（如住院）的支出，但很少有严格的VBID研究，特别是对整体临床或支出结果的影响。《病人保护和平价医疗法案》（ACA）要求所有医疗保险受益人从2011年开始免费获得预防服务，从而创造了一个VBID自然实验。这种费用分摊的消除有可能减轻美国预防服务工作组（USPSF）推荐的癌症筛查测试的使用不足。利用来自大型医疗保险优势计划的信息，该项目将研究ACA授权的医疗保险政策变化的临床和经济影响。我们2007-2014年的数据包含有关保险福利，个人特征，测试，临床事件和医疗支出的详细，全面的信息。研究样本包括受益人，他们在投保前有一系列费用分摊数额，随着时间的推移，费用分摊（免费筛查）逐步取消。例如，2007年有46%的研究人群接受了免费的结直肠癌筛查，2010年为74%，2011年为100%;所有的福利变化都发生在每年的1月1日。这三个目标检查了费用分摊变化的直接和总体影响：目标1）筛查率;目标2）临床事件率;目标3）总医疗支出。我们将评估所有受试者和说明性亚组的结局，例如，根据USPSTF的建议，筛选可能具有高或低价值的受试者。我们的主要分析将集中在人内变化（固定效应估计），并将调整丰富的人口统计学，临床，医生和系统特征。我们还将比较费用分担受试者与非费用分担受试者，使用在整个研究期间始终接受免费筛选的受试者作为并行对照。有了数百万人年的数据，我们将有足够的能力检测到我们结果中甚至很小的变化。这项研究提供了一个机会，以评估迄今为止最大的VBID自然实验，以检查一个主要的ACA条款对获得预防保健的早期影响，并告知未来的医疗保险政策决定。 公共卫生相关性： 这项研究将检查提供免费癌症筛查的医疗保险受益人的影响，根据最近的病人保护和负担得起的医疗法案的要求。虽然免费筛查在直观上很有吸引力，但有有限的证据表明，取消患者费用分摊将提高筛查率，对某些类型筛查的价值存在争议，以及对医疗支出总体影响的相当大的争论。这项工作将为医疗保险和国家卫生政策决策以及提高护理质量和效率的持续努力提供信息。

DESCRIPTION (provided by applicant): Aligning health insurance benefits with clinical goals, aka value-based insurance design (VBID), holds much promise for reducing financial barriers to recommended care, improving quality, and modulating spending growth. While studies have found that patient cost-sharing can reduce the use of necessary care and increase spending for downstream care such as hospitalizations, there have been few rigorous VBID studies, especially of the effects on overall clinical or spending outcomes. The Patient Protection and Affordable Care Act (ACA) requires that all Medicare beneficiaries have free access to preventive services starting in 2011, thus creating a VBID natural experiment. This elimination of cost-sharing has the potential to mitigate underuse of cancer screening tests recommended by the US Preventive Services Task Force (USPSF). Using information from large Medicare Advantage plans, this project will examine the clinical and economic effects of this ACA- mandated Medicare policy change. Our 2007-2014 data contain detailed, comprehensive information on insurance benefits, individual characteristics, testing, clinical events, and medical spending. The study sample includes beneficiaries with a range of pre-policy cost-sharing amounts with the staggered elimination of cost- sharing (free screening) over time. For example, 46% of the study population had free colorectal cancer screening in 2007, 74% in 2010, and 100% in 2011; all benefit changes occur on January 1st of the year. The three aims examine the cost-sharing changes' direct and overall effects: Aim 1) screening test rates; Aim 2) clinical event rates; and Aim 3) total medical spending. We will evaluate the outcomes in all subjects and illustrative subgroups, e.g., subjects for whom screening may be of high or low value as per the USPSTF recommendations. Our primary analyses will focus on within-person changes (fixed effects estimation), and will adjust for a rich set of demographic, clinical, physician, and system characteristics. We also will compare subjects with cost-sharing versus those without cost-sharing, using as concurrent controls subjects who consistently have free screening throughout the study period. With several million person-years of data, we will have adequate power to detect even small changes in our outcomes. This study provides an opportunity to evaluate the largest VBID natural experiment to date, to examine the early effects of a major ACA provision on access to preventive care, and to inform future Medicare policy decisions. PUBLIC HEALTH RELEVANCE: This study will examine the effects of providing free cancer screening to Medicare beneficiaries, as required by the recent Patient Protection and Affordable Care Act. While free screening is intuitively appealing, there is limited evidence that eliminating patient cost-sharing will increase screening rates, controversy over the value of some types of screening, and considerable debate about the overall effects on medical spending. This work will inform Medicare and national health policy decisions and ongoing efforts to improve the quality and efficiency of care.