The Effect of Patient Dementia on Outpatient Clinicians' Performance on Cost Outcomes Under Medicare

联系PD/PI：约翰斯顿、Daughon James 项目摘要 医疗保险计划正在实施基于价值的支付（VBP），向门诊临床医生支付费用 基于他们提供的医疗服务的质量和成本。然而，越来越多的人担心这些越南船民 程序可能不能准确地测量为高风险患者群体服务的临床医生的表现， 特别是那些患有阿尔茨海默病和相关痴呆（下文称为“痴呆”）的人。先前的研究发现 痴呆症与患者预后较差和护理成本明显较高独立相关。 此外，痴呆症患者倾向于聚集在某些类型的临床医生中，例如 老年病学家然而，尽管医疗保险调整了临床医生在VBP下的表现， 他们的病人使用医疗保险和医疗补助服务中心的分层条件类别（CMS- HCC）风险模型，它不适用于痴呆症。这可能导致系统性低估 为痴呆症患者提供不成比例服务的临床医生的表现。因此，有一个关键的 需要研究患者痴呆症对VBP下临床表现指标的影响，这是如何实现的？ 影响不成比例地为这些患者提供服务的提供者，以及痴呆症的措施是否可以 CMS-HCC医疗保险风险调整模型。我们的长期目标是采取措施， 将老年痴呆症患者的风险纳入医疗保险在实施VBP时使用的风险调整系统。的目标 这个R21应用程序是：1）验证基于索赔的痴呆症措施的充分性; 2）评估 通过将其添加到标准CMS中，实现基于索赔的护理成本模型（包括痴呆症）的性能- HCC风险模型;以及3）证明我们的新模型与标准CMS-HCC模型相比， 临床医生在MIPS和更广泛的计划中的成本措施上的相对表现。我们这样做的理由 该项目是，大多数临床医生在美国将被追究责任，他们的表现对成本的措施 根据VBP，有一个重大的风险，临床医生谁不成比例地服务于痴呆症患者 如果风险调整不考虑这些因素，可能会受到负面影响。本研究将 追求三个具体目标。对于目标#1，我们将使用Medicare进行回顾性队列研究。 当前受益人调查（MCBS）与处方药和索赔数据相关联，以验证索赔的使用- 基于痴呆症患者自我报告和处方药数据的测量。对于目标#2，我们将使用 CMS虚拟研究数据中心（VRDC）提供的最新可用Medicare索赔数据， 目前无法用CMS-HCC风险解释的可归因于痴呆症的医疗保险费用部分 模型，并评估通过增加痴呆患者的风险点来改善预测的模型。对于目标#3， 我们将使用CMS VRDC和医师比较数据来评估基于索赔的风险调整的影响 对于痴呆症，临床医生在VBP成本结果、绩效评分和报销方面的表现， 将不成比例地为痴呆症患者服务的临床医生与其他医疗保险临床医生进行比较。 项目摘要/摘要第6页

Contact PD/PI: Johnston, Kenton James Project Summary The Medicare program is implementing value-based payment (VBP), in which outpatient clinicians are paid based on the quality and cost of the care they deliver. However, there is increasing concern these VBP programs may not accurately measure performance among clinicians who serve high-risk patient populations, particularly those with Alzheimer’s disease and related dementias (hereafter “dementia”). Prior research finds that dementia is independently associated with poorer patient outcomes and markedly higher costs of care. Furthermore, patients with dementia tend to be clustered among certain types of clinicians, such as geriatricians. However, although Medicare adjusts clinicians’ performance under VBP for the medical risk of their patients using the Centers for Medicare and Medicaid Services’ hierarchical condition category (CMS- HCC) risk model, it does not adjust for dementia. This could result in systematic under-estimation of performance for clinicians that disproportionately serve patients with dementia. Therefore, there is a critical need for research on the effect of patient dementia on measures of clinician performance under VBP, how this impacts providers who disproportionately serve such patients, and whether measures of dementia can be integrated into the CMS-HCC Medicare risk adjustment model. Our long-term goal is to incorporate measures of patient dementia into the risk adjustment system that Medicare uses in implementing VBP. The objectives of this R21 application are to: 1) validate the adequacy of claims-based measures of dementia; 2) evaluate the performance of a claims-based costs of care model that includes dementia by adding it to the standard CMS- HCC risk model; and 3) demonstrate the effects of our new model versus the standard CMS-HCC model on clinicians’ relative performance on cost measures in MIPS and the program more broadly. Our rationale for this project is that most clinicians in the U.S. will be held accountable for their performance on cost measures under VBP, and there is a significant risk that clinicians who disproportionately serve patients with dementia may be negatively impacted if these factors are not accounted for by risk adjustment. This research study will pursue three specific aims. For aim #1, we will conduct a retrospective cohort study using the Medicare Current Beneficiary Survey (MCBS) linked to prescription drug and claims data to validate the use of claims- based measures of dementia against patient self-report and prescription drug data. For aim #2, we will use the most recently available Medicare claims data from the CMS Virtual Research Data Center (VRDC) to identify the portion of Medicare costs attributable to dementia that are currently unexplained by the CMS-HCC risk model, and evaluate a model that improves prediction by adding risk points for dementia patients. For aim #3, we will use the CMS VRDC and Physician Compare data to assess the impact of claims-based risk adjustment for dementia on clinician performance on VBP cost outcomes, performance scores, and reimbursement, comparing clinicians who disproportionately serve patients with dementia to the rest of Medicare clinicians. Project Summary/Abstract Page 6