COMPARATIVE EFFECTIVENESS OF CARDIOVASCULAR DEVICES AND MEDICARE COST GROWTH

描述（由申请人提供）：要全面了解新医疗技术在改善人口卫生保健结果方面的相对有效性，就必须全面阐明新技术如何增加国家卫生保健成本。健康经济学家普遍认为，新技术是美国医疗保健成本上升的主要驱动因素，但新技术导致成本增长的确切机制尚不确定。同样不确定的是，当地医疗保健市场因素如何影响新技术带来的成本增加。最后，国家政策举措，如医疗保险的证据开发覆盖计划、诊断相关组（DRG）分配的变化以及DRG报销率的修改，如何影响医疗保险成本的增长率，目前还不清楚。植入式心血管装置是医疗保险计划中最昂贵的治疗方法之一，最近医疗保险和医疗补助服务中心决定覆盖药物洗脱冠状动脉支架（2003年）和颈动脉支架（2004年），以及植入式心律转复除颤器（2003年和2005年）的覆盖适应症，潜在地为医疗保险计划带来数十亿美元的额外年度支出。因此，更清楚地了解将这些设备引入临床实践如何影响医疗保险成本增长，可以为预测未来医疗保险支出提供关键信息，从而为有关这些新技术（以及类似的未来创新）相对于成本的相对有效性的决策提供信息。在这个项目中，我们将分析2001年至2008年的国家医疗保险索赔数据，以实现以下目标：(1)衡量这3种心血管新技术增加医疗保险支出的程度，并评估成本增长可归因于技术直接成本的增加、护理量的扩大、接受治疗的患者特征的变化、补充医疗支出的增加和下游成本变化的比例；(2)确定由于这3种新的心血管技术而导致的成本增长如何在小的地理区域内变化，并评估可归因于市场层面因素的技术相关成本增长的比例，如医院竞争的强度、医疗保健市场中心脏专科医院的存在，或参与设备临床试验的医院的存在；(3)探讨关于这三种技术的医疗保险覆盖决策和政策的差异，包括不同的报销机构要求以及医院报销新诊断相关组的使用差异，如何影响医疗保险成本的增长。

DESCRIPTION (provided by applicant): Essential to a complete understanding of the comparative effectiveness of new medical technologies in improving population health care outcomes is a complete elucidation of how new technologies increase national health care costs. New technology is widely considered by health economists to be the leading driver of rising U.S. health care costs, yet the precise mechanisms by which new technologies produce cost growth are uncertain. It is likewise uncertain how local-area health care market factors have affected cost increases due to new technology. Finally, it is not well understood how national policy initiatives such as Medicare's Coverage with Evidence Development program, changes in diagnosis-related group (DRG) assignment, and modifications in DRG reimbursement rates have affected the rate of growth in Medicare costs. Implantable cardiovascular devices are among the most costly therapies covered by the Medicare program, and recent Centers for Medicare and Medicaid Services coverage decisions for drug-eluting coronary stents (2003) and carotid arterial stents (2004), as well as expansions of coverage indications for implantable cardioverter defibrillators (2003 and 2005), potentially have entailed billions of dollars in additional annual expenditures for the Medicare program. As such, a clearer understanding of how the introduction of these devices into clinical practice affected Medicare cost growth can critically inform the forecasting of future Medicare expenditures, and thus inform decisions regarding the comparative effectiveness of these new technologies (and similar, future innovations) relative to costs. In this project, we will analyze national Medicare claims data from 2001- 2008 in pursuit of the following goals: (1) to measure the degree to which these 3 new cardiovascular technologies have increased Medicare expenditures, and to assess the proportion of the cost growth that can be attributed to the increases in the direct cost of the technology, expansion in the volume of care, changes in the characteristics of patients undergoing treatment, increases in complementary health care expenditures, and changes in downstream costs; (2) to determine how cost growth due to these 3 new cardiovascular technologies has varied across small geographic areas, and to assess the proportion of technology-related cost growth that is attributable to market-level factors such as the intensity of hospital competition, the presence of cardiac specialty hospitals within a health care market, or the presence of hospitals there were involved in clinical trials of the devices; and (3) to explore how differences in Medicare's coverage decisions and policies regarding these three technologies, including differing institutional requirements for reimbursement as well as variation in the use of new diagnosis-related groups for hospital reimbursement, affected growth in Medicare costs.