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大有希望。虽然有研究发现，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，特别是对总体临床或支出结果的影响。《患者保护和平价医疗法案》（Patient Protection and Affordable Care Act， ACA）要求，从2011年开始，所有医疗保险受益人都可以免费获得预防服务，从而创建了一个VBID自然实验。取消费用分摊有可能减轻美国预防服务工作组（USPSF）建议的癌症筛查检测的使用不足。利用来自大型医疗保险优势计划的信息，该项目将检查这项ACA授权的医疗保险政策变化的临床和经济影响。我们2007-2014年的数据包含详细、全面的信息，包括保险收益、个人特征、测试、临床事件和医疗支出。研究样本包括受益人的一系列政策前的成本分摊金额与交错消除成本分摊（免费筛选）随着时间的推移。例如，2007年46%的研究人群进行了免费的结直肠癌筛查，2010年74%，2011年100%；所有的福利变化都在每年的1月1日发生。这三个目标考察了成本分担变化的直接和总体影响：目标1)筛查率；目的2)临床事件发生率；目标3)总医疗支出。我们将评估所有受试者和说导性亚组的结果，例如，根据USPSTF建议，筛查可能具有高或低价值的受试者。我们的主要分析将集中在个人变化（固定效应估计），并将根据人口统计学、临床、医生和系统特征进行调整。我们还将比较有费用分担的受试者与没有费用分担的受试者，同时使用在整个研究期间一直进行免费筛查的受试者作为对照。有了数百万人年的数据，我们将有足够的能力来检测我们的结果，即使是很小的变化。本研究提供了一个机会来评估迄今为止最大的VBID自然实验，以检查主要ACA条款对获得预防性护理的早期影响，并为未来的医疗保险政策决策提供信息。

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.