Medicaid Expansion and Quality, Utilization and Coordination of Health Care for Veterans with Chronic Kidney Disease

慢性肾病退伍军人医疗补助的扩展以及医疗保健的质量、利用和协调

• 批准号: 10833998
• 负责人: LAURA A PETERSEN
• 金额: --
• 依托单位: MICHAEL E DEBAKEY VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-04-01 至 2025-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10833998
• 关键词: 3-Dimensional; Accident and Emergency department; Accountability; Adopted; Affect; Affordable Care Act; American; Cardiovascular Diseases; Caring; Characteristics; Chronic; Chronic Kidney Failure; Complex; Comprehensive Health Care; Data; Diabetes Mellitus; Dialysis procedure; Dual Enrollment; Eligibility Determination; Emergency department visit; Emotional; Enrollment; Ensure; Face; Feeling; Financial Contribution; Health; Health Care Costs; Health Services Accessibility; Health system; Healthcare; Healthcare Systems; Hospitalization; Household; Improve Access; Income; Insurance Carriers; Interview; Investigation; Kidney; Kidney Diseases; Low income; Mediating; Medicaid; Medicaid eligibility; Medicare; Methodology; Mission; Modeling; Natural experiment; Outcome; Outpatients; Patient Care; Patients; Pattern; Persons; Primary Care Physician; Process; Provider; Quality of Care; Research; Resources; Risk; Services; Severity of illness; Source; Strategic Planning; Structure; Subgroup; System; Time; Transplantation; Uninsured; Uninsured Medical Expense; United States Dept. of Health and Human Services; Veterans; Visit; Work; beneficiary; care coordination; care costs; care fragmentation; care outcomes; care systems; comorbidity; cost; demographics; enhanced care; experience; falls; health care availability; health care delivery; health care quality; health care service; health care service utilization; improved; improved outcome; innovation; medical specialties; member; mortality; payment; policy recommendation; programs; tool; tool development

Background: [The 2019 US Department of Health and Human Services Advancing American Kidney Health Initiative aims to “improve care coordination…for people living with kidney disease.” Accessing care from multiple systems and insurers can result in lapses in care coordination, and] patients with serious conditions, such as chronic kidney disease (CKD), are especially vulnerable to poorer outcomes from fragmented care. [While Medicaid expansion, as occurred with the Affordable Care Act (ACA),] is effective in improving access to health care and health outcomes for the uninsured, the significant number of Veterans enrolled in VA (who already have access to comprehensive care) who gained access to Medicaid with expansion face increased risk of care fragmentation. Increased use of non-VA care as a result of the MISSION Act poses similar risks.] Significance/Impact: As more Veterans access care from a mixture of VA and non-VA sources, VA needs to adopt strategies for cross-system care coordination to ensure effective and efficient care for Veterans. This requires understanding how Veterans utilize care when multiple options are available. Patients with advanced CKD have highly complex care needs. Lack of well-coordinated care may increase unnecessary care and worsen outcomes for such patients. Examining use and outcomes data will illustrate multiple aspects of access and care coordination for Veterans with chronic conditions and anticipates implementation of the MISSION Act. Innovation: [That some states opted out of ACA Medicaid expansion allows for a natural experiment where changes in quality of care and utilization over time can be compared between states that did and did not expand Medicaid. The team will use VA, Medicare, and recently-released post-expansion Medicaid claims data to evaluate how Medicaid expansion influences Veteran choices of health system use and CKD treatment.] Specific Aims: Aim 1: To determine the characteristics of Veterans and Veterans with CKD who are most likely to enroll in both Medicaid and VA. Aim 2: To determine the impact of dual enrollment on the utilization of health care services for Veterans with advanced CKD and to create a reference tool to enhance coordination for these patients. Aim 3: To evaluate differences in quality of health care and costs among Veterans with advanced CKD in states that have expanded Medicaid and those that have not. Methodology: Claims data [from 17 states (7 that expanded Medicaid in 2014 and 10 that did not) in the Medicaid Analytic eXtract (MAX) file for 2011-2014] are included. A difference-in-difference model will estimate the association of state Medicaid expansion with [changes in Veterans’ dual-enrollment status (VA and Medicaid) and in utilization and outcomes for Veterans with CKD. Utilization analyses will consider outpatient visits, emergency department visits and hospital admissions recorded in VA and Medicaid data. Outcomes to be considered are time-to-mortality, emergent vs. elective initiation of dialysis, and costs to the health care system.] Each analysis contains demographics, comorbidity and illness severity. For all aims, separate models for low-income (Priority 5) Veterans are estimated as a sensitivity check. [In addition, strategies to support enhanced care coordination will be gathered from interviews with renal care teams and organizational leaders then developed into a care coordination reference tool for those who provide care for patients with kidney disease. Input from Veterans and patients will be incorporated at each stage of the interview and reference tool development process. Next Steps/Implementation: Veteran/patient and VA operational (National Kidney Program; Office of Veterans Access to Care) partners will be provided with interim and final findings to guide strategic planning and to inform programs that support optimal care for Veterans with access to multiple sources of care. Results from this project will be of great importance as stakeholders plan for Veteran needs in the form of direct health care services and effective care coordination, and as they make state and national policy recommendations.]

背景：[2019年美国卫生与公众服务部推进美国肾脏健康 该倡议旨在“改善肾脏疾病患者的护理协调”。不关心， 多个系统和保险公司可能导致护理协调失误，以及]病情严重的患者， 如慢性肾脏疾病（CKD），特别容易受到分散护理的影响。 [虽然医疗补助的扩大，如《平价医疗法案》（ACA）所发生的那样，]在改善获得方面是有效的。 对于没有保险的人来说，医疗保健和健康结果，大量的退伍军人参加了VA（谁 已经获得全面护理的人）获得医疗补助的人数增加 护理碎片化的风险。由于《使命法案》，增加使用非退伍军人事务部护理也会带来类似的风险。 意义/影响：随着越来越多的退伍军人从VA和非VA来源的混合中获得护理，VA需要 采取跨系统护理协调战略，确保退伍军人得到有效和高效的护理。这 需要了解退伍军人如何利用护理时，有多种选择。晚期 CKD具有高度复杂的护理需求。缺乏协调良好的护理可能会增加不必要的护理， 这类患者的预后更差。审查使用和结果数据将说明获取的多个方面 和照顾协调退伍军人与慢性疾病，并预计执行使命法。 创新：[一些州选择退出ACA医疗补助扩张，这允许进行一项自然实验， 可以比较实施和未实施的国家之间的护理质量和利用率随时间的变化 扩大医疗补助。该团队将使用VA，Medicare和最近发布的扩展后Medicaid索赔数据 评估医疗补助的扩大如何影响退伍军人对卫生系统使用和CKD治疗的选择。 具体目标：目标1：确定退伍军人和退伍军人CKD患者的特征， 可能会参加医疗补助和退伍军人事务部。目标2：确定双重入学对利用 为患有晚期CKD的退伍军人提供医疗保健服务，并创建一个参考工具，以加强协调 对于这些患者。目的3：评估退伍军人之间的医疗保健质量和成本的差异， 在已经扩大医疗补助的州和没有扩大医疗补助的州， 方法：索赔数据[来自17个州（7个州在2014年扩大了医疗补助计划，10个州没有）， 包括2011-2014年的Medicaid Analytic eXtract（MAX）文件]。差异中的差异模型将估计 州医疗补助扩张与[退伍军人双重注册状态的变化（VA和 医疗补助）和CKD退伍军人的利用和结果。利用分析将考虑门诊患者 在VA和Medicaid数据中记录的访问、急诊室访问和住院。成果与 应考虑至死亡时间、紧急透析与选择性透析启动以及医疗保健成本 系统。]每项分析均包含人口统计学、合并症和疾病严重程度。对于所有目标，单独的模型 对于低收入（优先5）退伍军人估计为敏感性检查。[In此外，支持战略 通过与肾脏护理团队和组织领导人的访谈， 然后开发成一个护理协调参考工具，供那些为肾病患者提供护理的人使用。 疾病在访谈和参考工具的每个阶段都将纳入退伍军人和患者的意见 发展过程 下一步/实施：退伍军人/患者和VA操作（国家肾脏计划;办公室 退伍军人获得护理）合作伙伴将提供中期和最终调查结果，以指导战略规划 并告知支持退伍军人获得多种护理来源的最佳护理的计划。结果 作为利益相关者以直接健康的形式计划退伍军人的需求， 护理服务和有效的护理协调，并作为他们提出国家和国家政策建议。