Natural Experiment of Value-Based Incentives for Preventive Services

描述(由申请者提供)：经济激励可以成为影响健康护理行为的有力工具。文献表明，与费用分担程度较低的患者相比，费用分担水平较高的患者对预防服务的使用率较低，但针对儿童的研究很少，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结合，也就是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)的一个核心特征。ACA要求所有健康保险计划取消高价值预防服务的费用分担，包括美国预防服务工作组(USPSTF)和疾病控制和预防中心(CDC)自2011年起建议的服务；然而，ACA免除现有雇主赞助(即团体)保险计划的这些保单，前提是这些计划的福利或价格不发生重大变化。因此，这些“祖辈”计划中的个人继续面临相同的预防保健费用分担。我们将利用这一自然实验来研究取消每年健康检查和免疫接种的费用分摊对儿童和青少年(21岁以下)的影响。未经USPSTF推荐的费用分摊变化和测试的团体健康保险计划的个人同时提供比较信息。使用MarketScan数据库和Kaiser Permanente的数据，该项目将检查ACA授权的健康保险政策变化对我们结果的早期临床和经济影响：目标1)办公室就诊率；目标2)免疫接种；以及目标3)总医疗支出。我们的数据包含有关保险福利、个人特征、免疫接种、临床事件和医疗支出的详细、全面的信息。研究样本包括具有一系列基线费用分摊金额和费用分摊变化时间的受试者。我们的主要分析将集中于人内的变化(固定影响估计)，并将根据丰富的人口统计、临床和系统特征进行调整。拥有数百万人年的数据，我们将有足够的能力检测我们结果中的微小变化。

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.