Natural Experiments to Understand Plan and Provider Behavior in an Era of Accountability

了解责任时代的计划和提供者行为的自然实验

• 批准号: 10616700
• 负责人: John Michael McWilliams
• 金额: $ 33.88万
• 依托单位: HARVARD MEDICAL SCHOOL
• 依托单位国家: 美国
• 财政年份: 2009
• 资助国家: 美国
• 起止时间: 2009-04-15 至 2025-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10616700
• 关键词: Accountability; Acute; Affect; Age; Area; Caring; Coinsurance; Competitive Bidding; Contracts; County; Data; Data Sources; Disabled Persons; Elderly; Enrollment; Evaluation; Evolution; Fee-for-Service Plans; Goals; Health; Health Promotion; Health care facility; Heterogeneity; Hospitals; Incentives; Length of Stay; Link; Managed Care; Measurement; Measures; Medicaid; Medicare; Methodology; Methods; Modeling; Monitor; Natural experiment; Nature; Outcome; Outcome Measure; Patient Care; Patient-Focused Outcomes; Patients; Performance; Personal Satisfaction; Physicians; Population; Positioning Attribute; Privatization; Process; Production; Prospective Payment System; Provider; Randomized; Research; Residual state; Resources; Risk; Risk Adjustment; Risk Assessment; Services; Skilled Nursing Facilities; Sorting; Source; System; Variant; accountable care organization; acute care; base; beneficiary; bundled payment; care delivery; cost; design; dual eligible; experience; financial incentive; flexibility; geographic difference; health plan; high reward; improved; improved outcome; insight; intrinsic motivation; patient population; payment; physical therapist; programs; provider behavior; response; risk selection; risk sharing; tool; wasting

ABSTRACT Payment to providers and plans in Medicare has far-reaching implications for the health of the elderly and disabled. The fee-for-service basis for payment has been rightly criticized for incentivizing excessive and potentially harmful provision of care and for interfering with the production of health by linking reimbursement to specific inputs. To establish greater flexibility and accountability, Medicare has increasingly transferred financial risk to entities that can manage care—first to private plans in the Medicare Advantage (MA) program and more recently to providers directly in alternative payment models (APMs) in traditional Medicare (TM). In both models, additional payment adjustments are tied to performance on quality measures. These approaches to integrating the financing and delivery of care create opportunities to improve patient care, but empirical study has been challenging. Evidence on the merits of the MA program and the relative performance of MA and APMs has been largely observational and limited in analysis of patient experiences and health outcomes. In addition, risk contracting relies heavily on risk adjustment to profile plan or provider performance and to align resources with the needs of patient populations, but the adequacy of risk adjustment has not been well described. This project will make substantial contributions by leveraging natural experiments and new data to understand plan and provider responses to payment incentives and their implications for patients and payment system design. The project includes three aims. First, we will use natural experiments to compare performance between MA and TM and different variants of each system. Sources of quasi-randomization to MA vs. TM will include differences across state and county borders in MA exposure and transitions from Medicaid to dual eligibility at age 65 in areas of high or low MA exposure. We will explore effect heterogeneity based on geographic variation in the configuration of MA (e.g., by plan type) and TM (e.g., by APM activity). Second, we will assess the marginal value of post-acute care in skilled nursing facilities (SNFs) and effects of incentives to alter post-acute length of stay on patient outcomes in different payment models, including TM, MA, and APMs. Post-acute care is an area of intense activity in MA and APMs that offers insights into provider agency. Approaches will make use of discontinuities in SNF reimbursement and coinsurance related to length of stay and natural randomization of patients to physical therapists in hospitals. Third, we will determine the extent to which risk-adjusted MA-TM differences in outcomes reflect performance differences vs. residual risk selection and assess the adequacy of risk-adjustment methods. We will use strategies from our first aim to compare MA- TM performance differences in self-sorted vs. quasi-randomized populations. Findings will characterize the prospects for value-enhancing competition or unintended consequences from prospective payment systems and will have important implications for the validity of quality scores. Thus, the project will provide foundational evidence and insights for improving health through payment systems and performance monitoring.

摘要 向医疗保险中的提供者和计划付款对老年人的健康有着深远的影响， 禁用.按服务收费的支付基础受到了正确的批评，因为它鼓励了过度的， 可能有害的护理提供，并通过将报销与医疗费用挂钩， 具体的投入。为了建立更大的灵活性和问责制，医疗保险越来越多地转移到 在Medicare Advantage（MA）计划中，可以管理护理优先到私人计划的实体的财务风险 以及最近在传统Medicare（TM）中的替代支付模型（APM）中直接提供给提供者。在 在这两种模式下，额外的付款调整与质量措施的表现挂钩。这些方法 整合融资和提供护理创造机会，以改善病人护理，但经验 研究是具有挑战性的。关于千年评估方案优点和千年评估相对业绩的证据 和APM在很大程度上是观察性的，在分析患者经历和健康结果方面受到限制。 此外，风险承包在很大程度上依赖于风险调整，以了解计划或提供商的业绩，并与 资源与患者人群的需求，但风险调整的充分性并不好 介绍了该项目将通过利用自然实验和新数据， 了解计划和提供者对支付激励措施的反应及其对患者和支付的影响 系统设计该项目包括三个目标。首先，我们将使用自然实验来比较性能 MA和TM以及每个系统的不同变体之间的差异。MA与TM的准随机化来源将 包括州和县边界之间MA风险的差异以及从医疗补助到双重医疗补助的过渡 在高或低MA暴露地区，65岁的资格。我们将基于以下因素探索效应异质性： MA配置的地理变化（例如，按计划类型）和TM（例如，APM活动）。二是 将评估熟练护理机构（SNF）中急性期后护理的边际价值以及激励措施的效果， 在不同的支付模式下，包括TM、MA和APM，改变急性期后住院时间对患者结局的影响。 急性期后护理是MA和APM的一个密集活动领域，为提供者代理提供了见解。 方法将利用SNF报销和与停留时间相关的共同保险的不连续性 和自然随机化的病人到医院的物理治疗师。第三，我们将确定 风险调整后的MA-TM结果差异反映了性能差异与剩余风险选择 并评估风险调整方法的适当性。我们将使用第一个目标中的策略来比较MA- 自分类与准随机化人群的TM性能差异。调查结果将描述 增值竞争的前景或预期支付系统的意外后果 并将对质量分数的有效性产生重要影响。因此，该项目将提供基础 通过支付系统和绩效监测改善健康的证据和见解。