Examining payment and delivery model impacts on health equity using novel quasi-experimental causal inference methods

6000万人参加了联邦医疗保险，7500万人参加了医疗补助，使这些计划成为 在美国医疗体系中最有影响力的。通过它们，联邦和州政府定期 试验新的支付和交付模式，在数百万受益人身上试验政策想法。一个 这项实验的关键实验室是医疗保险和医疗补助创新中心(The Innovation (Center：行情)，该公司最近承诺“让股权成为每种模式的核心.” 新的支付和交付模式可能会扩大差距(例如，通过不充分的风险调整和 选择)，改善它们(例如，通过灵活报销解决健康的社会决定因素)，或 两者(跨越不同的结果和分组)。然而，现有的方法并不能很好地适用于估计 这些计划对健康公平的影响。 医疗保险和医疗补助计划和政策，因为它们很少是随机的，所以使用以下方法进行评估 观察性因果推理方法。一种流行的这种方法是差异法(Diff-in-Diff)， 它比较了接触新模型的人与同一时间内的变化的结果的变化 在一组没有接触该模型的人中。虽然对总体计划影响有用， 标准的DIFF-in-DIFF方法不适用于股权评估。目标标的尚未制定 对于股票问题，它们不能适应不同子组的不同回答，也没有考虑到 治疗效果的变化。此外，这些方法没有以卫生公平框架为基础。 因此，没有使用为经历不成比例劣势的群体量身定做的因果假设。 部分由于这些方法上的缺陷，现有的关于医疗保险公平影响的证据 另一种支付模式是稀疏和混合的。初级保健转型模式收到的更少 请注意。我们建议开发和应用新的方法来研究全面初级保健加 (CPC+)影响黑人医疗保险受益人的医疗保健。这是全国先进的初级保健医疗 家居模式在2017-18年在18个地区推出，并将持续到2021年。我们的具体目标 1)评估CPC+对黑人医疗保险受益人的医疗保健和健康公平的影响，2) 交叉法估计黑人医疗保险受益人亚群对CPC+反应的差异 性别、残疾和医疗补助双重资格的身份，以及3)探索对以下问题的反应差异 CPC+跨越两个背景维度：初级保健实践特征和当地医疗保健和 社会经济环境。本申请是对NOT-HS-21-014特别强调通知的响应 (森)：AHRQ宣布对卫生服务研究感兴趣，以促进卫生公平。

60 million people are enrolled in Medicare and 75 million in Medicaid, making these programs among the most influential in the US health care system. Through them, federal and state governments regularly experiment with new models of payment and delivery, trying out policy ideas on millions of beneficiaries. A key laboratory for this experimentation is the Center for Medicare and Medicaid Innovation (the Innovation Center), which has recently committed to “make equity a centerpiece of every model.” New payment and delivery models may either widen disparities (e.g., through inadequate risk adjustment and selection), ameliorate them (e.g., by addressing social determinants of health with flexible reimbursement), or both (across different outcomes and subgroups). However, existing methods are not well suited to estimate these programs' impacts on health equity. Medicare and Medicaid programs and policies, because they are rarely randomized, are evaluated using observational causal inference methods. One popular such method is difference-in-differences (diff-in-diff), which compares changes in outcomes for people exposed to a new model versus changes over the same time in a comparison group of people not exposed to the model. While useful for overall program impacts, standard diff-in-diff methods are not suited to equity evaluations. The target estimands are not formulated for equity questions, they do not accommodate varying responses across subgroups, and they do not account for variation in treatment effects. In addition, the methods are not grounded in frameworks for health equity and thus fail to use causal assumptions tailored for groups who experience disproportionate disadvantage. Partly because of these methodological shortcomings, existing evidence on equity impacts of Medicare alternative payment models is sparse and mixed. Primary care transformation models have received even less attention. We propose to develop and apply novel methods to study how Comprehensive Primary Care Plus (CPC+) affects health care for Black Medicare beneficiaries. This national advanced primary care medical home model was introduced across 18 regions in 2017-18 and will continue through 2021. Our specific aims are 1) To estimate impacts of CPC+ on health care and health equity for Black Medicare beneficiaries, 2) To estimate variation in responses to CPC+ within subgroups of Black Medicare beneficiaries with intersecting identities of gender, disability, and dual eligibility for Medicaid, and 3) To explore variation in responses to CPC+ across two contextual dimensions: primary care practice characteristics and the local health care and socioeconomic environment. This application is in response to NOT-HS-21-014 Special Emphasis Notice (SEN): AHRQ Announces Interest in Health Services Research to Advance Health Equity.