Joint Effect of Malpractice Risk and Financial Incentives on Cardiac Testing

描述(由申请人提供)：心脏测试是医疗保健成本和成本增长的主要贡献者。有大量证据表明，心脏测试被过度使用。过度使用的两个潜在原因是测试提供者的盈利能力，以及他们对医疗事故责任的担忧。我们研究的一个中心目标是研究责任风险和财务激励如何单独和共同影响心脏测试率和患者结果。没有之前的 这项研究考察了这两个因素对心脏检测率的影响；任何医疗领域的先前研究都没有研究责任风险和经济激励之间的相互作用。这些互动很可能是重要的。如果测试是有利可图的，那么渎职风险和盈利能力都可能导致测试过度使用。相反，如果检测是无利可图的，医疗事故风险可能会为检测率提供“底线”，从而限制未充分使用。我们将研究这些问题，依赖于外部冲击对渎职风险和补偿的影响，作为可信的因果推断的基础。对于渎职行为，我们将依靠过去十年的州改革，在此期间，有九个州采用了新的损害上限。在报销方面，我们将依靠联邦医疗保险和医疗补助服务中心(CMS)从2010年开始大幅削减门诊压力测试的报销。这些削减的赌注很大。如果这些削减遏制过度使用，CMS每年将实现数十亿美元的节省，并可能在其他地方采用类似的削减。然而，如果测试从门诊转移到住院设置，或者提供者取代不面临削减的更昂贵的测试，支出可能会上升。此外，如果检测率降至最佳水平以下，削减可能会损害患者的利益。为了评估医疗事故风险的影响，我们将研究采用侵权改革的州，并将其他州作为控制组。对于报销削减，我们将研究联邦医疗保险服务费中的心脏测试，使用联邦医疗保险优势患者作为对照组。该项目的目的是：(1)单独评估医疗事故改革对检测率的影响；(2)评估单独削减报销对检测率和地点的影响；(3)研究医疗事故风险和报销削减之间的相互作用；以及(4)评估医疗事故风险和报销水平如何单独和共同影响患者结果。了解这些改革的综合影响对于确保近2000万美国冠状动脉患者的优质护理至关重要 疾病(CAD)以及每年接受检测的更多人。此外，医疗事故和支付改革方面的大规模试验正在进行中，不仅限于心脏护理。我们的研究可以为几个领域的政策决策提供参考，包括：(I)医疗事故责任能否限制以前玷污了“管理型医疗”并可能破坏“责任医疗”成功的治疗不足的风险？(Ii)报销削减，例如对门诊压力测试的削减，是否可以限制测试的过度使用，或者它们是否会产生意想不到的后果--无论是提高成本还是降低医疗质量？(Iii)医疗事故风险的最佳水平如何随医疗机构报销的性质而变化？

DESCRIPTION (provided by applicant): Cardiac testing is a major contributor to health care costs and cost growth. There is substantial evidence that cardiac testing is overused. Two potential reasons for overuse are test profitability to providers and their fear of medical malpractice liability. A central goal of our study is to examine how liability risk and financial incentives, individually and jointly influence cardiac testing rates and patient outcomes. No prior study examines the impact of either factor on cardiac testing rates; no prior study in any area of medical care studies the interactions between liability risk and financial incentives. These interactions are likely to be important. If testing is profitable, both malpractice risk and profitability could induce test overuse. In contrast, if testing is unprofitable, malpractice risk could provide a "floor" on testing rates, and thus limit underuse. We will study these issues, relying on external shocks to malpractice risk and reimbursements as a basis for credible causal inference. For malpractice, we will rely on state reforms over the last decade, during which nine states adopted new damage caps. For reimbursements, we will rely on large cuts by the Centers for Medicare and Medicaid Services (CMS), beginning in 2010, to reimbursement for outpatient stress testing. The stakes for these cuts are large. If these cuts curb overuse, CMS would achieve billions of dollars of annual savings and might adopt similar cuts elsewhere. However, spending could rise if testing moves from outpatient to inpatient settings, or providers substitute more expensive tests which did not face cuts. Additionally, the cuts could harm patients if testing rates fall below the optimal level. To assess the impact of malpractice risk, w will study states that adopted tort reforms, using other states as a control group. For reimbursement cuts, we will study cardiac testing within Medicare fee-for-service, using Medicare Advantage patients as the control group. The project aims are to: (1) assess the impact of malpractice reforms alone on testing rates; (2) assess the impact of reimbursement cuts alone on testing rates and locations; (3) examine the interaction between malpractice risk and reimbursement cuts; and (4) assess how malpractice risk and reimbursement levels individually and jointly affect patient outcomes. Understanding the combined impact of these reforms is critical to ensure quality care for the nearly 20 million Americans with coronary artery disease (CAD) and the many more who are tested for it each year. Moreover, large scale experiments in both medical malpractice and payment reform are underway, not limited to cardiac care. Our research can inform policy decisions in several areas, including: (i) can malpractice liability limit the risks of undertreatment that previously tainted "managed care" and might undermine the success of "accountable care"?; (ii) can reimbursement cuts, such as those made to outpatient stress testing limit test overuse, or will they have unintended consequences - either raising cost or degrading care quality?; and (iii) how does the optimal level of malpractice risk vary with the nature of provider reimbursement?