Medicaid Accountable Care Organizations (ACO) and Quality of Care for Adults with Serious Mental Illness (SMI)

医疗补助责任护理组织 (ACO) 和患有严重精神疾病的成人的护理质量 (SMI)

• 批准号: 10591570
• 负责人: Anna Goldman
• 金额: $ 18.94万
• 依托单位: BOSTON MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2022
• 资助国家: 美国
• 起止时间: 2022-03-14 至 2026-02-28
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10591570
• 关键词: Address; Adult; Affect; Ambulatory Care; American; Benchmarking; Caring; Case Manager; Cessation of life; Characteristics; Chronic Care; Data; Development Plans; Drops; Enrollment; Evolution; Funding; General Population; Goals; Health; Health Insurance; Health Policy; Health Services Accessibility; Healthcare; Homelessness; Hospital Administrators; Hospitals; Incentives; Individual; Insurance Claim Review; Interview; Investigation; Leadership; Low income; Massachusetts; Measures; Medicaid; Medical; Medicare; Mental Health; Methods; Modeling; National Institute of Mental Health; Natural experiment; Organizational Affiliation; Organizational Models; Outcome; Patient Care; Patients; Perception; Policies; Policy Maker; Population; Proliferating; Provider; Quality Indicator; Quality of Care; Randomized; Research; Research Personnel; Selection Bias; Shapes; Source; Strategic Planning; Structure; System; accountable care organization; barrier to care; care coordination; career development; comorbidity; experience; health care delivery; health care service organization; hospital readmission; improved; insight; parity; participant enrollment; patient population; payment; premature; programs; risk selection; severe mental illness; social; social adversity; social vulnerability; tool

PROJECT SUMMARY Individuals with serious mental illness (SMI) are three times more likely to die prematurely than the general population. Sixty percent of this premature death is attributable to inadequate care of chronic, co-morbid medical conditions. A growing proportion of patients with SMI receive care in accountable care organizations (ACOs) – health care delivery and finance systems, in which global payments and quality benchmarks are used to incentivize quality care and lower spending. An increasing number of states are implementing ACO models in their Medicaid programs, the primary source of health insurance for low-income Americans with SMI. Medicaid ACOs exist in 12 states, caring for over 6% of the Medicaid population. Medicaid ACOs have the potential to both improve and worsen access to, and quality of, care for low-income adults with SMI. While financial structures that incentivize care coordination and programs that address health-related social needs likely benefit those with SMI, inadequate global payments that fail to account fully for social adversities such as homelessness could result in lower quality care. Certain features of Medicaid ACOs, e.g. leadership structure or ACO size, may amplify the benefits or drawbacks of the ACO model for patients with SMI. Evidence from Medicare ACOs has shown that smaller, provider-led ACOs and those serving a lower proportion of socially- vulnerable patients perform better in terms of quality. However, no evidence exists on how Medicaid ACO characteristics affect quality of care or the care experience of SMI adults. Since Medicaid ACOs are rapidly proliferating, filling this evidence gap is critical and can inform the evolution of the ACO model to better achieve the goal of mental health parity. In this K23 research plan, we propose to identify features of Medicaid ACOs (e.g. provider-led vs. hospital-led ACOs) that produce the highest quality ACO care for adults with SMI. We will undertake this research objective in three critical domains. First, we will study whether certain ACO types tend to drop patients with SMI, a practice known as favorable risk selection (or “cherry-picking”). This phenomenon can cause instability of ACO enrollment for patients, itself a marker of lower quality care. Second, we will compare care access and quality among adults receiving care in different ACO types. Lastly, we will use mixed methods to examine the care experiences of adults with SMI receiving care in different ACO types, through in-depth interviews and subsequent integration of qualitative and quantitative findings. For the first two aims, we will use Massachusetts All-Payer Claims Data and leverage the state’s unique auto- assignment mechanism as a natural experiment to study favorable risk selection, access, and quality. Auto- assignment refers to Medicaid randomly assigning individuals to ACOs, allowing us to compare outcomes across ACO types without selection bias caused by patients self-selecting their ACO affiliation. The goal of my K23 research is to guide policymakers and hospital administrators in shaping the Medicaid ACO model to produce more stable, higher-quality ACO care for patients with SMI.

项目总结 患有严重精神疾病(SMI)的人过早死亡的可能性是一般人的三倍 人口。这种过早死亡的60%可归因于对慢性、合并症的护理不足 医疗条件。越来越多的SMI患者在负责任的护理机构接受护理 (ACOS)-医疗保健提供和融资系统，其中全球支付和质量基准是 用于激励高质量的医疗保健和降低支出。越来越多的州正在实施ACO 他们的医疗补助计划中的模式，这是患有SMI的低收入美国人的主要医疗保险来源。 医疗补助ACO存在于12个州，覆盖了超过6%的医疗补助人口。医疗补助ACO拥有 有可能改善和恶化对患有重度精神障碍的低收入成年人的获得和护理质量。而当 激励护理协调的金融结构和满足与健康相关的社会需求的方案 可能使那些患有SMI的人受益，这些不充分的全球支付未能完全考虑到社会逆境，例如 无家可归者可能会导致护理质量下降。医疗补助ACO的某些特征，例如领导结构 或ACO的大小，可能会放大SMI患者ACO模型的优点或缺点。证据来自 联邦医疗保险ACO表明，规模较小、由提供者主导的ACO以及那些服务于较低比例的社会- 易受伤害的患者在质量方面表现得更好。然而，没有证据表明医疗补助ACO 这些特征会影响SMI成人的护理质量或护理体验。由于医疗补助ACO迅速 扩散，填补这一证据空白是至关重要的，并可以推动ACO模型的演变，以更好地实现 心理健康平等的目标。在这项K23研究计划中，我们建议确定医疗补助ACO的特征 (例如，提供商主导与医院主导的ACO)，为患有SMI的成年人提供最高质量的ACO护理。我们 将在三个关键领域开展这一研究目标。首先，我们将研究某些ACO类型 倾向于放弃患有SMI的患者，这种做法被称为有利的风险选择(或“挑剔”)。这 这种现象会导致ACO患者登记的不稳定，而ACO本身就是低质量护理的标志。 其次，我们将比较接受不同类型ACO护理的成年人的护理机会和质量。最后， 我们将使用混合的方法来检查患有SMI的成年人在不同的ACO接受护理的经历 通过深入访谈以及随后的定性和定量调查结果的整合，确定了不同的类型。对于 前两个目标，我们将使用马萨诸塞州的所有付款人索赔数据，并利用该州独特的自动- 分配机制作为研究有利风险选择、准入和质量的自然实验。自动- 分配指的是医疗补助计划随机将个人分配给ACO，允许我们比较结果 在不同的ACO类型中，没有因患者自行选择他们的ACO从属关系而导致的选择偏见。我的目标是 K23研究旨在指导政策制定者和医院管理者塑造医疗补助ACO模式，以 为SMI患者提供更稳定、更高质量的ACO护理。