The Effect of Reduction and Standardization of Reimbursements in the VA Fee-Basis Program: Impact on Quality of Care and Health Outcomes

VA 收费计划中报销减少和标准化的效果：对护理质量和健康结果的影响

• 批准号: 9757710
• 负责人: Vincent Mor
• 金额: --
• 依托单位: PROVIDENCE VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2017
• 资助国家: 美国
• 起止时间: 2017-02-01 至 2020-01-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/9757710
• 关键词: Address; Adoption; Affect; Amputation; Businesses; Caring; Characteristics; Chronic; Communities; Contracts; Control Groups; Cost Savings; Data; Data Set; Dialysis procedure; Effectiveness; End stage renal failure; Enrollment; Ensure; Evaluation; Expenditure; Facility Controls; Fee Schedules; Fees; Floor; Future; Geography; Goals; Health; Health Services Accessibility; Hospitalization; Improve Access; Information Systems; Institutes; Interdisciplinary Study; Kidney; Kidney Diseases; Kidney Failure; Maintenance; Medicare; Modeling; Myocardial Infarction; Outcome; Patient Care; Patients; Pattern; Performance; Policies; Population; Price; Process; Provider; Quality of Care; Renal dialysis; Research; Secure; Series; Services; Site; Standardization; Stroke; System; Testing; Time; Transfusion; United States; Vendor; Veterans; base; bundled payment; care delivery; care outcomes; comorbidity; complex chronic conditions; cost; design; experience; health care availability; health care service; high risk; improved; insight; minority communities; mortality; payment; programs; simulation; treatment group

Many Veterans enrolled in the VHA who require dialysis receive this service from non-VA dialysis providers. Historically reimbursement to non-VA dialysis providers was highly variable, with payments up to roughly 3-times the uniform Medicare reimbursement rate. In 2010 the VHA standardized and reduced dialysis reimbursements to about 130 percent of the Medicare fee schedule in order to curb rising Fee Basis expenditures for dialysis care. The VA further streamlined non-VA dialysis care payments in 2013 by issuing national dialysis contracts to ensure a more efficient process of identifying and reimbursing dialysis providers for Veterans. The new payment mechanism to non-VA dialysis providers was expected to reduce “fee dialysis” expenditures by 50%, but the realized cost savings may not materialize if the payment policy adversely impacts the quality of care provided to Veterans. There was little evidence to guide these efforts and now, more than ever, rigorous evaluation is needed to understand how these payment models for outsourced dialysis services changed the patterns of dialysis care delivery and to understand how policy changes may have altered the quality of dialysis services to Veterans. Now, more than ever, rigorous evaluation is needed to: (1) understand how these payment models for outsourced dialysis services affect the pattern of dialysis care delivery; (2) determine how changes in purchasing policy affected Veterans' access to care and the quality of their experience; and (3) provide insight about how the delivery of outsourced dialysis care for Veterans can be improved. This study will estimate the impact of these policy changes on Veterans and to determine whether a geographically contingent, value based model for purchasing dialysis services from non-VA vendors could improve the overall outcomes experienced by Veterans requiring dialysis. In order to address the Aims of our proposal, we bring together a multi-site, multi-disciplinary research team that is aptly suited to conduct this study. We employ a rich array of data sets from the VA, United States Renal Data System, and Medicare that span a decade of patient care (2006-2015). In order to unravel the causal effect of the policy on dialysis-related hospitalization and mortality, we estimate a difference-in- difference model that compares the average pre-post policy differences in the outcomes between Veterans that are undergoing dialysis in non-VA facilities (treatment group) and their counterparts that are undergoing dialysis in VA-owned facilities (control group). Findings from this study will provide much needed evidence to understand the extent to which VA's payment and purchasing policies for non-VA care have impacted the quality of dialysis care and Veterans' outcomes. Furthermore, results will inform future policies and practices for purchasing dialysis care as well as those governing implementation of the Veteran's Choice Act. By informing the future direction of VA strategy, this research seeks to improve the quality and accessibility of health care services while optimizing value and is consistent with VHA Blueprint for Excellence goals.

许多参加 VHA 需要透析的退伍军人从非 VA 透析获得这项服务 提供商。从历史上看，非 VA 透析提供者的报销金额变化很大，最高可达 大约是统一医疗保险报销率的3倍。 2010 年，VHA 标准化并减少了透析 报销 Medicare 费用表的约 130%，以遏制费用基础上涨 透析护理费用。 2013 年，VA 进一步简化了非 VA 透析护理付款流程，发布了 国家透析合同，以确保更有效地识别和补偿透析提供者 对于退伍军人。针对非 VA 透析提供商的新支付机制预计将减少“透析费用” 支出减少 50%，但如果支付政策不利，所实现的成本节约可能无法实现 影响向退伍军人提供的护理质量。几乎没有证据可以指导这些努力，现在， 比以往任何时候都更需要严格的评估来了解这些外包支付模式如何 透析服务改变了透析护理服务的模式，并了解政策变化将如何影响 改变了退伍军人透析服务的质量。 现在，比以往任何时候都更需要严格的评估来：（1）了解这些支付模式如何 外包透析服务影响透析护理服务的模式； (2) 确定如何变化 购买政策影响退伍军人获得护理的机会及其体验质量； (3) 提供见解 关于如何改善退伍军人外包透析护理的提供。这项研究将估计 这些政策变化对退伍军人的影响，并确定地理上的偶然性、价值是否 从非 VA 供应商购买透析服务的基于模型可以改善整体结果 需要透析的退伍军人经历过。 为了实现我们提案的目标，我们汇集了多地点、多学科的研究 非常适合进行这项研究的团队。我们采用来自美国 VA 的丰富数据集 肾脏数据系统和跨越十年患者护理（2006-2015）的医疗保险。为了解开谜底 政策对透析相关住院率和死亡率的因果影响，我们估计差异 差异模型，比较退伍军人之间结果的平均政策实施前差异 正在非 VA 机构（治疗组）接受透析的患者及其正在接受透析治疗的患者 在 VA 拥有的设施中进行透析（对照组）。这项研究的结果将为以下问题提供急需的证据： 了解 VA 对非 VA 护理的支付和购买政策对非 VA 护理的影响程度 透析护理的质量和退伍军人的结果。此外，结果将为未来的政策和实践提供信息 用于购买透析护理以及管理《退伍军人选择法》的实施。经过 本研究旨在为 VA 战略的未来方向提供信息，旨在提高 VA 的质量和可及性 医疗保健服务，同时优化价值，并符合 VHA 卓越蓝图目标。