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Unintended Consequences: Medicare Performance Programs and Health Disparities

意想不到的后果：医疗保险绩效计划和健康差异

基本信息

批准号：
9077010
负责人：
Amresh D Hanchate
金额：
$ 59.23万
依托单位：
BOSTON MEDICAL CENTER
依托单位国家：
美国
项目类别：
财政年份：
2016
资助国家：
美国
起止时间：
2016-04-01 至 2018-11-30
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/9077010
关键词：
Acute Acute myocardial infarction Admission activity Affect Affordable Care Act Ambulatory Care Benchmarking Caring Clinical Data Development Ethnic Origin Evaluation Financial compensation Healthcare Heart failure Home environment Hospitals Income Inpatients Intervention Investments Lead Low income Maps Measures Medical Medicare Methodology Methods Minority Modification Outcome Patient Care Patient-Focused Outcomes Patients Performance Pneumonia Policy Maker Process Quality of Care Race Reporting Research Design Resources Rewards Risk Severities Social support Socioeconomic Status Uncompensated Care Underinsured Uninsured base disadvantaged population ethnic disparity ethnic minority population experience family support financial incentive health disparity high risk hospital readmission improved minority-serving hospitals mortality patient safety payment programs public health relevance racial and ethnic racial disparity racial minority safety net socioeconomics

项目摘要

DESCRIPTION (provided by applicant): In recent years, the healthcare landscape has undergone transformational changes, through public reporting of hospital performance, promotion of medical homes, and development of global payment mechanisms, all directed at improved quality and value of care. To accelerate and solidify this process, the Patient Protection and Affordable Care Act (ACA) of 2010 mandated two programs of performance-based financial incentives covering a majority of hospitals nationwide: the Hospital Readmissions Reduction Program (HRRP) and the Value-Based Purchasing (VBP) program. Beginning in 2012, the programs incentivized an increase ("reward") or decrease ("penalty") in Medicare reimbursement rates based on hospital performance on a range of measures - readmissions, process of care, patient experience of care, mortality - some covering all patients and others covering patients with acute admissions for acute myocardial infarction, heart failure, and pneumonia. Although intended to encourage evaluation and improvement of quality-of-care processes, these programs have raised considerable concern for potential adverse impact in hospitals that care for disproportionately large share of racial and ethnic minorities ("minority-serving hospitals") or uninsured and underinsured patients ("safety-net hospitals"). First, evidence indicates that patient outcomes, such as readmissions, are affected by factors beyond the influence of hospital processes, including access to outpatient care, and family and social supports; consequently, HRRP and VBP, using hospital benchmarks that make no allowance for differences in patient socio-demographic or clinical severity profiles, may lead to higher risk of penalties for minority-serving and safety-net hospitals. Second, as minority-serving and safety-net hospitals provide more uncompensated care, leading to greater reliance on public subsidies, their investments for quality-of-care improvements are likely to be smaller; to compound this challenge, financial penalties from the Medicare programs may have a greater adverse impact for patient care and outcomes in the resource-poor hospitals due to their low operating margins. To evaluate these concerns, the proposed study aims to examine data from the implementation experience of these programs. Using Medicare patient-level and hospital-level data (2008-2015), and a difference-in-differences study design based on comparison of hospitals exposed to the programs with those not exposed, we aim to estimate program effects on (a) hospital performance, and (b) patient outcomes - 30- day mortality and readmission - by race/ethnicity and socioeconomic status. In addition, we will explore alternative modifications in performance programs to incentivize safety-net and minority-serving hospitals to improve quality of care.

描述(由申请人提供)：近年来，医疗保健领域发生了翻天覆地的变化，通过公开报告医院业绩、推广医疗机构和发展全球支付机制，所有这些都旨在提高医疗质量和价值。为了加快和巩固这一进程，2010年的《患者保护和平价医疗法案》(ACA)规定了两项基于绩效的财务激励计划，覆盖全国大多数医院：医院再入院减少计划(HRRP)和基于价值的采购(VBP)计划。从2012年开始，这些计划根据医院的一系列指标--重新入院、护理过程、患者的护理体验、死亡率--对医疗保险报销率的提高(“奖励”)或降低(“惩罚”)进行激励，其中一些指标涵盖所有患者，另一些指标涵盖急性心肌梗死、心力衰竭和肺炎的急性入院患者。虽然这些方案的目的是鼓励评估和改进护理质量过程，但对于那些照顾不成比例的种族和族裔少数群体的医院(“少数族裔服务医院”)或未参保和保险不足的患者(“安全网医院”)的潜在不利影响，这些方案引起了相当大的关注。首先，有证据表明，患者的结果，如重新入院，受到医院流程影响之外的因素的影响，包括获得门诊护理以及家庭和社会支持；因此，HRRP和VBP使用的医院基准没有考虑患者社会人口或临床严重程度的差异，可能会导致少数族裔服务的医院和安全网医院受到更高的处罚风险。其次，由于少数群体服务和安全网医院提供更多的无偿医疗服务，导致更多地依赖公共补贴，它们在改善医疗质量方面的投资可能会较小；使这一挑战复杂化的是，由于运营利润率较低，来自联邦医疗保险计划的经济处罚可能会对资源贫乏的医院的患者护理和结果产生更大的不利影响。为了评估这些关切，拟议的研究旨在检查这些方案实施经验中的数据。使用联邦医疗保险患者水平和医院水平的数据(2008-2015)，以及基于暴露于该计划的医院与未暴露的医院的比较的差异研究设计，我们旨在按种族/民族和社会经济地位评估计划对(A)医院绩效和(B)患者结果-30天死亡率和再入院-的影响。此外，我们将探索绩效计划的替代修改，以激励安全网和少数群体服务的医院提高护理质量。