Synergies and Sequencing in Delivery and Payment Reform: Understanding What Works

为了解决持续存在的成本和质量挑战，美国政策制定者寻求多种交付和 支付改革。替代支付模式（APM）是最新拟议改革的关键组成部分 MACRA，建立在我们过去 5 年尝试的交付和支付改革的基础上。 其中包括： 1) 医疗保险和医疗补助电子健康记录激励计划，也称为 “有意义的使用”（MU），向采用和使用经过认证的电子健康记录作为核心信息的提供商付费 临床文件； 2) 以患者为中心的医疗之家 (PCMH) 计划，其目标是护理流程 确保初级保健可及、协调良好且以团队为基础； 3) 责任关怀 协调初级保健提供者、医院和其他机构的财务激励的组织 (ACO) 计划 供应商提高质量和价值。每个项目都有相关的证据表明 检查其有效性。然而，迄今为止的研究尚未确定初级保健提供者的模式 参与，以及组合和排序如何相互作用以影响最终收益的大小。 我们的项目专注于捕捉 MU 和 PCMH 项目的参与模式和近期影响 ACO 工作的背景，因为它们是 APM 的关键组成部分。它们也都是自愿项目， 新政府预计将强调自愿参与。我们建议审查 这些计划预计将改善一系列成果：坚持循证护理， 减少可避免的医院利用率（例如，门诊护理敏感入院），以及减少 支出。我们计划使用二级数据源来捕获初级保健提供者对 MU 的参与情况， PCMH 和 ACO 计划以及有关患者结果的 Medicare 索赔数据，以 (1) 识别 初级保健实践参与提供系统改革工作（MU 和 PCMH）和支付改革 （ACO），以及模式是否因实践特征而异； (2) 检验初级保健实践的影响 参与交付系统改革工作（MU 和 PCMH），以实现这些计划的目标成果；和 (3) 测试初级保健实践参与支付改革 (ACO) 对支付改革的影响程度 参与交付系统改革工作所带来的收益的大小。我们的研究很重要，因为它 系统评估改善初级保健的主要政策努力的影响。我们的研究具有创新性 因为它探讨了不同的交付和支付改革努力之间的相互作用，以便提供信息 APM 可能产生的影响并指导未来政策的设计。

To address persistent cost and quality challenges, US policymakers have pursued multiple delivery and payment reforms. Alternative payment models (APMs), a key component of the latest proposed reforms under MACRA, build on the delivery and payment reforms that we have experimented with over the past 5 years. These include: 1) Medicare and Medicaid Electronic Health Record Incentive Programs, also known as “Meaningful Use” (MU), which pay providers for adopting and using certified electronic health records for core clinical documentation; 2) Patient-Centered Medical Home (PCMH) programs that target care processes that ensure that primary care is accessible, well-coordinated, and team-based; and 3) Accountable Care Organization (ACO) programs that align financial incentives of primary care providers, hospitals, and other providers to improve quality and value. Each of these programs has an associated body of evidence that examines its effectiveness. However, research to date has not identified the patterns of primary care provider participation, and how the combination and sequencing interact to affect the magnitude of resulting gains. Our project is focused on capturing participation patterns and near-term effects of MU and PCMH programs in the context of ACO efforts because these are key components of APMs. They are also all voluntary programs, and voluntary participation is expected to be emphasized by the new Administration. We propose to examine a set of outcomes that are expected to improve under these programs: adherence to evidence-based care, reductions in avoidable hospital utilization (e.g., ambulatory-care sensitive admissions), and reductions in spending. We plan to use secondary data sources that capture primary care provider participation in MU, PCMH, and ACO programs along with Medicare claims data on patient outcomes to (1) Identify patterns of primary care practice participation in delivery system reform efforts (MU and PCMH) and payment reform (ACOs), and whether patterns vary by practice characteristics; (2) Test the impact of primary care practice participation in delivery system reform efforts (MU and PCMH) on outcomes targeted by these programs; and (3) Test the extent to which primary care practice participation in payment reform (ACOs) impacts the magnitude of gains from engagement in delivery system reform efforts. Our study is significant because it systematically assesses the impact of the major policy efforts to improve primary care. Our study is innovative because it explores the interactions between the varied delivery and payment reform efforts in order to inform the likely impact of APMs and guide the design of future policies.