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

为了应对持续存在的成本和质量挑战，美国政策制定者追求多次交付和 支付改革。替代支付模式(APM)，这是 Macra，在我们过去5年试验的交付和支付改革的基础上再接再厉。 这些措施包括：1)联邦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)，向采用和使用经认证的电子健康记录的供应商支付费用 临床文档；2)以患者为中心的医疗之家(PCMH)计划，目标是 确保初级保健可获得、协调良好、以团队为基础；以及3)负责任的保健 组织(ACO)计划，协调初级保健提供者、医院和其他机构的财务激励 供应商要提高质量和价值。这些计划中的每一个都有相关的证据 检验其有效性。然而，到目前为止，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，以影响所产生的收益的大小。 我们的项目重点是捕捉MU和PCMH项目的参与模式和近期影响 ACO努力的背景，因为这些是APM的关键组成部分。它们也都是志愿项目， 预计新一届政府将强调自愿参与。我们建议研究 在这些计划下有望改善的一系列结果：坚持循证护理， 减少可避免的医院使用率(例如，对门诊护理敏感的入院)，并减少 花销。我们计划使用二级数据源来捕捉初级保健提供者在MU中的参与情况， PCMH和ACO计划以及联邦医疗保险索赔患者结果的数据，以(1)确定 初级保健实践参与分娩系统改革努力(保健单位和初级保健保健机构)和支付改革 (ACOS)，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 就这些方案所针对的成果参与交付系统改革努力(MU和PCMH)；以及 (3)测试初级保健实践参与支付改革(ACOS)对 从参与交付系统改革努力中获得的巨大收益。我们的研究很有意义，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 因为它探索了各种交付和支付改革努力之间的相互作用，以便 行动计划可能产生的影响，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.