Learning from Medicare Payment Reform: Economic Effects of ACO Incentives

描述(由申请人提供)：政策制定者已经接受了按绩效支付和共享储蓄/风险的模式，以改善医疗保健并在公共资助的医疗保健计划中适度增加成本。公共和私人支付者都强烈承诺从基于数量的支付转向有价值的支付模式。《平价医疗法案》授权联邦医疗保险与负责任的医疗组织(ACO)签订合同，这些组织是负责特定人群的医疗保健的提供者网络。虽然这些计划的实施进展迅速，但几乎没有证据表明这些计划是否有潜力在提高质量的同时节省真正的成本。在此应用程序的R21阶段，我们将完成对Medicare的医生小组实践演示的评估，这是10个多专业医生小组的联合按绩效付费和共享储蓄努力。医生团体实践示范改革在许多方面与目前立法的ACO改革相似，因此是我们迄今拥有的关于ACO激励效果的最佳证据。然而，除了10个网站的奖金支付和质量得分公开报告外，人们对激励计划对整体的影响知之甚少 成本、质量或结果。我们的数据分析始于一个简单的差异策略，以当地联邦医疗保险受益人为对照，以衡量演示对联邦医疗保险支付的影响，以及超出支付目的衡量的质量指标。我们将把比较组扩大到当地控制之外的类似医生实践，并将重点放在对项目的选择和风险调整在成本和结果研究中的作用的核算上。此外，我们研究的一个主要目标将是开发一个医疗保险支付改革激励计划的结构模型，使用医生团体执业示范产生的结果估计参数，我们相信这可以解释提供者对PGPD反应的部分异质性。完成R21阶段的里程碑将包括开发ACO奖励计划的理论模型、完成适当的控制小组和评估选择模型、指定适当的质量和结果措施以及适当的风险调整措施。在应用程序的R33阶段，我们将把在R21阶段开发的技术和模型应用于先锋和联邦医疗保险共享储蓄计划，其中将包括更多负责任的护理组织参与者和激励设计中的更多微妙之处。

DESCRIPTION (provided by applicant): Policymakers have embraced pay-for-performance and shared savings/risk models to improve healthcare and moderate cost growth in publically funded healthcare programs. There is a strong commitment by both public and private payers to move from volume-based payment toward payment models rewarding value. The Affordable Care Act authorized Medicare to contract with accountable care organizations (ACOs), networks of providers responsible for the health care of a defined population. While implementation of these programs is moving forward rapidly, there is little evidence to guide whether these programs have the potential to yield real cost savings while improving quality. Under the R21 phase of this application, we will complete an evaluation of Medicare's Physician Group Practice Demonstration, a joint pay-for-performance and shared savings effort in 10 multi-specialty physician groups. The Physician Group Practice Demonstration reforms are similar in many respects to the currently legislated ACO reforms, and thus qualify as the best evidence we have to date of the effects of ACO incentives. Yet beyond bonus payments and quality scores publicly reported for each of the ten sites, little is known about how the incentive scheme affected overall costs, quality or outcomes. Our data analysis begins with a simple difference-in-difference strategy, with local Medicare beneficiaries as controls, to measure the effect of the Demonstration on Medicare payments and quality metrics beyond those measured for payment purposes. We will expand the comparison groups to similar physician practices beyond local controls and will focus on accounting for selection into the program and the role of risk adjustment in study of costs and outcomes. In addition, a major objective of our research will be to develop a structural model of Medicare payment reform incentive schemes, with parameters estimated using outcomes arising from the Physician Group Practice Demonstration, that we believe can explain some part of the heterogeneity observed in provider responses to the PGPD. The milestones for completion of the R21 phase will include development of a theoretical model of ACO incentive schemes, completion of appropriate control groups and estimation of a selection model, specification of appropriate quality and outcome measures, and adequate risk adjustment measures. In the R33 phase of the application, we will apply techniques and models developed in the R21 phase to the Pioneer and Medicare Shared Savings Programs, which will include a greater number of accountable care organization participants and more subtleties in incentive design.