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

为了应对持续的成本和质量挑战，美国政策制定者一直在追求多个交付， 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，建立在我们在过去5年中尝试的交付和支付改革的基础上。 这些措施包括：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），支付提供者采用和使用认证的电子健康记录的核心 临床文件; 2）以患者为中心的医疗之家（PCMH）计划，目标是 确保初级保健是可获得的、协调良好的和以团队为基础的;以及3）负责任的保健 组织（ACO）计划，使初级保健提供者、医院和其他 供应商提高质量和价值。每一个项目都有相关的证据， 检查其有效性。然而，迄今为止的研究还没有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，以影响所产生的收益的大小。 我们的项目重点是捕捉参与模式和近期效果的MU和PCMH计划， ACO工作的背景，因为这些是杀伤人员地雷的关键组成部分。它们也都是志愿项目， 预计新政府将强调自愿参与。我们建议研究 一组预期在这些项目下会得到改善的结果：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），并减少 支出.我们计划使用二级数据源，捕捉初级保健提供者参与MU， PCMH和ACO计划沿着有关患者结局的医疗保险索赔数据，以（1）确定 初级保健实践参与交付系统改革工作（MU和PCMH）和支付改革 （ACO），以及模式是否因实践特征而异;（2）测试初级保健实践的影响 参与交付系统改革工作（MU和PCMH），以实现这些方案的目标成果; (3)测试初级保健实践参与支付改革（ACO）对 参与交付系统改革工作的收益规模。我们的研究意义重大，因为它 系统地评估改善初级保健的主要政策努力的影响。我们的研究是创新的 因为它探讨了各种交付和支付改革努力之间的相互作用， （c）评估杀伤人员地雷可能产生的影响，并指导今后政策的设计。

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.