Effect of the patient-centered medical home on geographic and racial disparities in health care access

以患者为中心的医疗之家对医疗保健获取方面的地理和种族差异的影响

• 批准号: 10004638
• 负责人: Nathaniel Bell
• 金额: $ 5万
• 依托单位: UNIVERSITY OF SOUTH CAROLINA AT COLUMBIA
• 依托单位国家: 美国
• 财政年份: 2019
• 资助国家: 美国
• 起止时间: 2019-09-01 至 2022-08-31
• 项目状态: 已结题
• 来源: https://reporter.nih.gov/project-details/10004638
• 关键词: Effect; patient; centered; medical; home

Recent reviews of the overall quality of legislative initiatives to bolster preventative care and deter costs through the adoption of the Patient-Centered Medical Home (PCMH) model have been mixed. The reasons for these findings vary, and important gaps exist in our understanding of the circumstances in which some medical homes apparently flourish while others do not. In particular, the degree to which geography and associated social determinants of health drive variations in care quality is not well understood. This understanding is critical for promoting access standards of service availability given the geographic variation in which the medical homes are reaching the marketplace. As in other states, South Carolina’s Medicaid program recently began a state-established initiative to allow enrollees to obtain care through recognized PCMHs that participated in Medicaid Managed Care (MMC). Since that time, beneficiaries have been eligible to self-enroll into 297 of the 367 medical homes that are recognized by the National Committee for Quality Assurance and that participate in MMC. Although the program is available to enrollees across the state, 10% of the total Medicaid population must travel outside of their county of residence to access a PCMH. The four counties that contain half of all medical homes account for less than 30% of the total Medicaid population. Medicaid’s enrollment structure and distribution of medical homes provides an opportunity to conduct a ‘natural experiment’ to analyze whether longer travel distances and times to providers determines why the effects of some PCMH innovations are often muted. Using a difference-in-difference design, this study will examine whether the longer travel distances and times to care decreases observed differences in avoidable emergency department (ED) visits and avoidable inpatient hospitalizations. We will extend this analysis to minorities as well as populations living in racially segregated neighborhoods to determine if distance effects represent a higher burden to specific patient groups. Administrative data will be derived from a combination of Medicaid claims data for recipients that were consecutively enrolled from 2016 to 2018, street network data, and American Community Survey, which will be used to build socioeconomic and neighborhood segregation indices. The study analyzes accessibility thresholds that are already incorporated into MMC primary and specialty care contracts as a mechanism from which to recommend specific standards for PCMHs. Regression analyses will explore the relationship between travel times and distances on avoidable ED and inpatient visits by comparing PCMH enrollees to Medicaid recipients who have never entered into the PCMH program, examining the association between moderators (e.g., neighborhood segregation) and mediators (e.g., primary care quality) with proximity to preventive care. Findings will have relevance to current MMC network adequacy policy reform efforts and for establishing parameters about the location of PCMHs for optimum accessibility.

最近对加强预防保健和遏制成本的立法举措的总体质量进行了审查 通过采用以病人为中心的医疗之家（PCMH）模式，的原因 这些发现各不相同，我们对一些医疗机构在某些情况下的理解存在重要差距。 家庭显然兴旺发达，而其他家庭则不然。特别是，地理和相关的 健康的社会决定因素驱动护理质量的变化还不清楚。这种理解是 考虑到地理上的差异， 医疗之家正在走向市场。与其他州一样，南卡罗来纳州的医疗补助计划最近 开始了一项国家建立的倡议，允许登记者通过公认的PCMH获得护理， 参与Medicaid Managed Care（MMC）。从那时起，受益人有资格自行登记 进入国家质量保证委员会认可的367家医疗机构中的297家， 参加MMC的人。虽然该计划是提供给全国各地的注册者，10%的总数， 医疗补助人群必须前往他们居住的县以外的地方才能获得PCMH。这四个县， 包含所有医疗之家的一半，占医疗补助总人口的不到30%。医疗补助的 招生结构和分布的医疗之家提供了一个机会，进行'自然 实验"，以分析是否较长的旅行距离和时间的供应商决定了为什么影响 PCMH的一些创新往往是无声的。采用差异中差异设计，本研究将检查 较长的旅行距离和护理时间是否减少了可避免的紧急情况的观察差异 部门（艾德）访问和可避免的住院治疗。我们将把这种分析扩展到少数民族， 以及居住在种族隔离社区的人群，以确定距离效应是否代表了 对特定患者群体的负担更重。管理数据将来自医疗补助的组合 2016年至2018年连续登记的领取者的索赔数据，街道网络数据，以及 美国社区调查，将用于建立社会经济和邻里隔离 指数。该研究分析了已纳入MMC主要和 专科护理合同作为一种机制，从其中建议具体标准的PCMH。回归 分析将探讨可避免的艾德和住院就诊的旅行时间和距离之间的关系 通过比较PCMH登记者与从未进入PCMH计划的医疗补助接受者， 检查主持人之间的关联（例如，邻域隔离）和介体（例如，初级 护理质量）与预防护理接近。调查结果将与当前MMC网络充分性相关 政策改革努力，并为最佳无障碍环境建立关于PCMH位置的参数。