Can the Medicare Quality Payment Program Incentivize Evidence-Based Treatment of Depression and Anxiety Disorders by Primary Care Providers?

项目摘要 抑郁症和焦虑症在初级保健环境中的患者中很常见，并且有明确的证据- 基于筛查、诊断和治疗的指南。然而，筛查率、检测率和 医疗保险受益人的治疗水平仍然很低。如果没有适当的治疗，这些患者可能会经历 持续的抑郁和焦虑症状，难以共同管理其他慢性病，病情恶化 功能状态，以及可避免且代价高昂的急性医疗事件。2017年，医疗保险推出质保 支付计划(QPP)，以激励门诊患者提供高质量、低成本、循证的护理 布景。该计划涵盖各种替代支付模式(APM)，如以患者为中心的医疗 家庭(PCMH)和责任关怀组织(ACO)。在所有支付模式中，临床医生都是付费的 根据他们为患者提供的护理质量和成本来评价他们的表现。然而， 初级保健提供者(PCP)治疗抑郁症和焦虑症的QPP尚不清楚。那里 是否迫切需要研究QPP对获得护理和提供循证服务的影响 初级保健环境中抑郁症和焦虑症的治疗以及随后的结果 对病人来说。我们的科学前提是QPP，这是一个针对普通患者的计划 人口，可能会对初级保健的提供产生好坏参半的激励和意想不到的后果 患有抑郁症和焦虑症的患者。一方面，QPP激励初级保健医生承担更高的风险 ACOs和PCMHs等APM采用创新和协作的护理模式，可能会提高 循证治疗。然而，另一方面，QPP不会对最普遍的情况进行风险调整 当判断临床医生的表现时，抑郁症和焦虑症的类型，这产生了经济上的 不鼓励初级保健医生照顾患有这些疾病的患者，潜在地威胁到他们获得护理的机会。 此R01应用程序的目标是使用真实世界数据进行纵向研究，以评估 QPP对以下方面的影响：1)抑郁症和焦虑症患者跨支付模式获得PCP的机会 以及2)为这些疾病和随后的患者结果提供循证治疗。 这项研究将追求两个具体目标。对于目标1，我们将进行一项回溯性队列研究，使用 联邦医疗保险当前受益人调查、联邦医疗保险和医疗补助服务中心的纵向数据 虚拟研究数据中心和医生2017-2020年的对比，以调查两个假设：1) 患有抑郁症和焦虑症的受益者将较少获得风险较高的急性呼吸综合征患者的初级保健药物； 2)不成比例地对待患有这些疾病的受益人的初级保健医生将获得较低的合格初级保健计划绩效 分数和付款。对于目标2，我们将使用相同的数据来调查受益人 有了这些条件，APM中的PCP，如ACO和PCMH，将：1)获得更高的费率 循证治疗；2)有更好的健康和成本结果。

Project Summary Depression and anxiety disorders are common in patients in the primary care setting and have clear evidence- based guidelines for screening, diagnosis, and treatment. However, rates of screening, detection, and treatment among Medicare beneficiaries remain low. Without proper treatment, these patients may experience persistent depression and anxiety symptoms, difficulty co-managing other chronic conditions, worsening functional status, and avoidable and expensive acute medical events. In 2017, Medicare launched the Quality Payment Program (QPP) to incentivize delivery of high quality, low cost, evidence-based care in the outpatient setting. The program covers a variety of alternative payment models (APMs) such as patient-centered medical homes (PCMHs) and accountable care organizations (ACOs). Across all payment models, clinicians are paid for their performance based on the quality and cost of care they deliver to patients. However, the effects of the QPP on treatment of depression and anxiety disorders by primary care providers (PCPs) are unknown. There is a critical need for research on the effect of the QPP on access to care and delivery of evidence-based treatment for depression and anxiety disorders in the primary care setting, as well as the subsequent outcomes for patients. Our scientific premise is that the QPP, which is a program targeted at the general patient population, is likely to produce mixed incentives and unintended consequences for primary care delivery to patients with depression and anxiety disorders. On one hand, the QPP incentivizes PCPs in higher-risk bearing APMs such as ACOs and PCMHs to adopt innovative and collaborative care models that may increase rates of evidence-based treatment. However, on the other hand, the QPP does not risk adjust for the most prevalent types of depression and anxiety disorders when judging clinician performance, which creates a financial disincentive to PCPs for caring for patients with these conditions, potentially threatening their access to care. The objectives of this R01 application are to conduct a longitudinal study using real-world data to evaluate the effect of the QPP on: 1) access to PCPs across payment models for patients with depression and anxiety disorders; and 2) delivery of evidence-based treatment for these conditions and subsequent patient outcomes. This study will pursue two specific aims. For aim #1, we will conduct a retrospective cohort study using longitudinal data from the Medicare Current Beneficiary Survey, Centers for Medicare and Medicaid Services Virtual Research Data Center, and Physician Compare for 2017-2020 to investigate two hypotheses: 1) beneficiaries with depression and anxiety disorders will have less access to PCPs in higher risk-bearing APMs; 2) PCPs who disproportionately treat beneficiaries with these conditions will receive lower QPP performance scores and payments. For aim #2, we will use the same data to investigate the hypotheses that beneficiaries with these conditions with access to PCPs in APMs, such as ACOs and PCMHs, will: 1) receive higher rates of evidence-based treatment; 2) have better health and cost outcomes.