Natural Experiment of Value-Based Incentives for Preventive Services

描述（由申请人提供）：经济激励是影响医疗保健行为的有力工具。文献表明，面对高水平费用分担的患者比费用分担较少的患者更少使用预防服务，但在儿童中很少有研究，在任何人群中只有有限数量的研究表明，取消费用分担会增加预防服务的使用。这种保险福利设计与临床目标的一致性，又名基于价值的保险设计（VBID），是最近的患者保护和平价医疗法案（ACA）的核心特征。ACA要求所有健康保险计划取消高价值预防服务的费用分摊，包括美国预防服务工作组（USPSTF）和疾病控制与预防中心（CDC）推荐的服务；然而，《平价医疗法案》免除了现有的雇主赞助（即团体）保险计划的这些政策，前提是这些计划的福利或价格没有发生重大变化。因此，在这些“祖父”计划中的个人继续面临同样的预防保健费用分摊。我们将利用这一自然实验来研究取消年度健康检查和免疫接种费用分摊对儿童和青少年（21岁以下）的影响。参加团体健康保险计划的个人没有费用分担变化和USPSTF不推荐的测试，提供了并发的比较信息。使用来自MarketScan数据库和Kaiser Permanente的数据，该项目将检查aca授权的医疗保险政策变化对我们结果的早期临床和经济影响：目标1)诊所就诊率；目标2)免疫接种；目标3)总医疗支出。我们的数据包含详细、全面的信息，包括保险福利、个人特征、免疫接种、临床事件和医疗支出。研究样本包括具有一系列基线费用分摊额和费用分摊变化时间的受试者。我们的主要分析将集中在个人变化（固定效应估计）上，并将根据丰富的人口统计、临床和系统特征进行调整。有了数百万人年的数据，我们将有足够的能力来检测我们的结果，即使是很小的变化。

DESCRIPTION (provided by applicant): Financial incentives can be powerful tools to influence health care behavior. The literature suggests that patients faced with high levels of cost-sharing have lower use of preventive services than patients with less cost-sharing, but there are few studies in children and only a limited number of studies in any population demonstrating that the elimination of cost-sharing increases use of prevention. This alignment of insurance benefit design with clinical goals, aka value-based insurance design (VBID), is a central feature of the recent Patient Protection and Affordable Care Act (ACA). The ACA requires that all health insurance plans eliminate cost-sharing for high value preventive services including those services recommended by the US Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) as of 2011; the ACA, however, exempts existing employer-sponsored (i.e., group) insurance plans from these policies provided that the plans do not make major changes in their benefits or prices. Thus, individuals within these "grandfathered" plans continue to face the same cost-sharing for preventive care. We will exploit this natural experiment to examine how the elimination of cost-sharing for annual wellness visits and immunizations affects children and adolescents (age up to 21 years). Individuals enrolled in group health insurance plans without cost-sharing changes and tests not recommended by the USPSTF provide concurrent comparative information. Using data from the MarketScan Databases and from Kaiser Permanente, the project will examine the early clinical and economic effects of this ACA-mandated health insurance policy change on our outcomes: Aim 1) office visit rates; Aim 2) immunizations; and Aim 3) total medical spending. Our data contain detailed, comprehensive information on insurance benefits, individual characteristics, immunizations, clinical events, and medical spending. The study sample includes subjects with a range of baseline cost-sharing amounts and in the timing of cost-sharing changes. Our primary analyses will focus on within-person changes (fixed effects estimation), and will adjust for a rich set of demographic, clinical, and system characteristics. With several million person-years of data, we will have adequate power to detect even small changes in our outcomes.