Medicare in a Restructured Delivery System

描述（由申请人提供）：医疗保险计划中融资和医疗的成功整合是健康政策的唯一最重要的目标，并且可以说是当今美国社会和财政政策的最重要目标，它具有强大的预算含义。目前，医疗保险通过医疗保险优势（MA）计划促进综合护理，目前受益人入学率达到29%的历史新高。过去的增长是以高支付率为代价的，这在很大程度上转移了医疗保险计划和纳税人从整合中获得的收益。然而，支付率最近有所降低，阻碍了进一步扩大硕士招生。例如，2012年医疗保险受托人报告预计，到2020年，硕士入学率将降至17%。此外，最昂贵的医疗保险受益人，以及那些一体化提供最多的人，即所谓的“双重资格”，加入一体化计划的频率要低得多，尽管这种情况正在开始改变。按照目前的结构，硕士项目并没有解决将大量受益人转移到综合护理计划，提高他们的护理质量，同时节省项目资金的难题。医疗保险需要创新，它需要可靠的经济分析来评估当前的举措，并为修改或新方法提供科学依据。医疗保险在医疗服务提供者支付方面进行了创新，比如负责任医疗组织（ACO）项目，其设计给受益人的感觉就像传统医疗保险（TM）。供应商团体自愿参与ACO，通过整合实现效率并获得财务奖励。ACOs是否可以在成本或质量上改善现有的TM和MA的医疗保险替代方案，同时对受益人和提供者的奖励进行轻微调整，这是一个悬而未决的问题，需要立即给出有效的答案。然而，重要的是，除了ACOs之外，必须考虑关于医疗保险整合的新想法。本项目申请提出了一个前瞻性的研究议程，包括三个领域：1)对当前举措的创新和全面分析，2)对当前整合形式的严格研究，正如我们的研究所显示的那样，硕士课程近年来的表现有所改善，3)对创新受益人和提供者支付政策的研究。

DESCRIPTION (provided by applicant): Successful integration of financing and care in the Medicare program is the single most important objective of health policy, and arguably, with its powerful budgetary implications, of social and fiscal policy in the US today. Currently, Medicare promotes integrated care through the Medicare Advantage (MA) program, presently at an historic high in beneficiary enrollment of 29%. Past growth came at the cost of high payment rates, which largely transferred any gains from integration away from the Medicare program and taxpayers. Payment rates have recently been reduced, however, handicapping further expansion of MA enrollment. The 2012 Medicare Trustees Report, for example, projects MA enrollment will fall to 17% by 2020. Furthermore, the most costly Medicare beneficiaries, and the ones for whom integration has the most to offer, the so-called "dual eligibles," have joined integrated plans much less frequently, though that is beginning to change. As currently constituted, the MA program has not solved the riddle of moving large numbers of beneficiaries to integrated care plans, improving the quality of their care, and at the same time saving program funds. Medicare needs innovation, and it needs sound economic analysis to evaluate current initiatives and provide the scientific basis for modifications or new approaches. Medicare is innovating in provider payment with programs such as the Accountable Care Organization (ACO) programs, designed to feel like Traditional Medicare (TM) to beneficiaries. ACO participation is voluntary for provider groups with financial rewards for achieving efficiencies through integration. Whether ACOs can improve on the current Medicare alternatives of TM and MA with respect to either cost or quality with a light touch on beneficiaries and rewards for providers is an open question to which an immediate valid answer is needed. Importantly, however, new ideas about integration in Medicare in addition to ACOs must be considered. This Program Project application lays out a forward-looking research agenda encompassing three areas: 1) innovative and comprehensive analyses of current initiatives, 2) rigorous research on the current form of integration, the MA program which, as our research has shown, has demonstrated improved performance in recent years, and, 3) research on innovative beneficiary as well as provider payment policy.