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

许多需要透析的VHA注册退伍军人从非VA透析中获得这项服务 提供商从历史上看，非VA透析提供者的报销变化很大， 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 报销约130%的医疗保险费用表，以遏制不断上升的费用基础 透析护理费用。VA在2013年通过发布以下文件进一步简化了非VA透析护理付款 国家透析合同，以确保更有效地识别和报销透析提供者 对于退伍军人。对非VA透析提供者的新支付机制预计将减少“透析费” 支出减少50%，但如果付款政策不利， 影响了退伍军人的护理质量。几乎没有证据来指导这些努力，现在， 比以往任何时候都更需要严格的评估，以了解这些外包的支付模式 透析服务改变了透析护理提供的模式，并了解政策变化如何可能 已经改变了退伍军人透析服务的质量。 现在，比以往任何时候都需要进行严格的评估，以：（1）了解这些支付模式如何 外包透析服务影响透析护理提供模式;（2）确定 购买政策影响退伍军人获得护理和他们的经验质量;（3）提供洞察力 关于如何为退伍军人提供外包透析护理。这项研究将估计 这些政策变化对退伍军人的影响，并确定是否有地理特遣队，价值 从非VA供应商购买透析服务的基于模型可以改善总体结局 需要透析的退伍军人的经历。 为了解决我们的建议的目的，我们汇集了多地点，多学科的研究 适合进行这项研究的团队。我们采用了来自美国弗吉尼亚州的丰富的数据集 肾脏数据系统和医疗保险，跨越了十年的病人护理（2006-2015）。为了解开 该政策对透析相关住院和死亡率的因果影响，我们估计了 差异模型，比较退伍军人之间的结果的平均前后政策差异 在非VA机构接受透析的患者（治疗组）及其正在接受 VA所属机构的透析（对照组）。这项研究的结果将提供急需的证据， 了解VA的支付和购买政策对非VA护理的影响程度 透析护理质量和退伍军人的结果。此外，研究结果将为今后的政策和做法提供参考 购买透析护理以及那些管理退伍军人选择法的实施。通过 本研究旨在为未来VA战略的发展提供信息， 同时优化价值，并与VHA卓越蓝图目标一致。

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.