Hospital-Physician Gainsharing

描述(申请人提供)：医疗保健费用在美国继续快速增长，但这笔支出的价值尚不确定。医生之间以及医院和医生之间的碎片化和错位的财务激励阻碍了基于价值的决策。在心脏病和整形外科等服务领域，医生决定使用被称为“医生偏好项目”的高成本药物和设备，但医院会为它们买单。一些支付者和提供者已经采用了基于群体的激励计划来改善一致性。一种被称为收益分享的方法目前正被私营部门的医院以及医疗保险和医疗补助示范项目中心使用。在收益分享制度下，如果费用相对于历史基线有所降低，医生小组将收到一笔必须在其成员之间平均分摊的款项。 这个项目的广泛目标是通过改进医生激励计划的设计来增加卫生保健决策的价值。在初步工作中，我们发现，2006年底之前实施的方案降低了成本，但没有减少现有的质量或准入措施。一个完整的理论模型为医院和医生如何在收益分享的激励下做出决定提供了洞察力。拟议的工作建立在这些成果的基础上，以实现三个具体目标：1)确定收益分享是否降低了药品和设备的利用率和医院的价格，以及如何实现任何降价；2)确定收益分享是否促进了医生治疗决策的协调和标准化；3)展示了医生对收益分享的反应如何不同。该项目还包括一个探索性目标：开发和测试经济模型，准确预测医生对替代激励计划的反应，包括不同设计的收益分享计划。 为了实现这些目标，我们建议检查所有在2009年底之前实施的心脏病学领域的私营部门收益分享计划。这涵盖了13家医院的多达25个收益分享项目，其中6个项目目前正在等待政府批准。我们依赖于2001-2009年丰富的专有数据集，其中包括所有这些收益共享计划以及来自大约130个其他非收益共享冠状动脉插管实验室的同期数据。这些数据包括每个医生为每个患者选择的每种药物和设备的详细信息，包括医院为它们支付的价格。它们还包括一组比行政数据更详细的风险调整变量。该项目有三个主要步骤：我们通过实证检验理论模型中的假设来确定医生对收益分享的反应；我们通过扩展和测试模型来发现医生对收益分享的反应不同的原因；以及我们通过开发结构模型来量化医生如何衡量激励计划的每个方面。这些结果可以为监管机构、政策制定者和管理人员提供及时的见解，帮助他们考虑通过协调来促进价值的各种激励计划。

DESCRIPTION (provided by applicant): Health care costs continue to grow quickly in the U.S., but the value of this spending is uncertain. Fragmentation and misaligned financial incentives among physicians and between hospitals and physicians inhibit value-based decision-making. In service areas such as cardiology and orthopedic surgery, physicians determine the use of high cost drugs and devices known as "physician preference items," but hospitals pay for them. Some payers and providers have adopted group-based incentive programs to improve alignment. One known as gainsharing is currently used by hospitals in the private sector as well as within Centers for Medicare and Medicaid demonstration programs. Under gainsharing, a physician groups receives a payment that must be equally shared among its members if costs are lowered relative to a historical baseline. The broad objective of this project is to increase the value of health care decision-making through improved design of physician incentive programs. In preliminary work, we found that the programs implemented before the end of 2006 reduced costs without reductions in the available measures of quality or access. A completed theoretical model provides insights to how hospitals and physicians make decisions under gainsharing's incentives. The proposed work builds off these results to achieve three specific aims: 1) to determine whether gainsharing reduces utilization and hospitals' prices of drugs and devices, and how any price reductions are achieved; 2) to determine whether gainsharing promotes coordination and standardization of physicians' treatment decisions; 3) to demonstrate how physicians vary in their responses to gainsharing. The project also includes one exploratory aim: to develop and test economic models that accurately predict physicians' responses to alternative incentive programs, including differently designed gainsharing programs. To achieve these goals, we propose to examine all of the private-sector gainsharing programs in cardiology implemented before the end of 2009. This covers up to 25 gainsharing programs at 13 hospitals, with six programs currently pending government approval. We rely on a rich, proprietary dataset from 2001-2009 that includes all of these gainsharing programs as well as contemporaneous data from approximately 130 other, non-gainsharing coronary catheterization laboratories. These data include detailed information about every drug and device chosen by every physician for every patient, including the price the hospital paid for them. They also include a more detailed set of risk-adjustment variables than available in administrative data. The project has three main steps: we determine how physicians responded to gainsharing by empirically testing the hypotheses from the theoretical model; we discover why physicians' responses to gainsharing varied by extending and testing the model; and we quantify how physicians weigh each aspect of the incentive program by developing a structural model. The results can provide timely insights to regulators, policymakers, and managers as they consider various incentive programs to promote value through coordination.