Medicaid Payment Policy and Access to Care for Dual Eligible Beneficiaries

摘要 该项目将评估初级保健提供者(PCP)支付政策对门诊、临床护理的影响 活动和医疗支出。该项目的重点是双重资格的联邦医疗保险和医疗补助受益人，因为他们 都是这两个项目中最昂贵、临床上最脆弱的人之一，而且在历史上 获得次优护理的机会。我们将评估临时提高医疗补助付款率的影响 2013年和2014年《平价医疗法案》(ACA)规定的初级保健计划；这项政策增加了初级保健计划 为符合双重资格的受益人支付高达25%的款项。这项政策的目的是改善获得 为低收入人口提供初级保健，特别是考虑到 私人保险和医疗补助覆盖的个人应根据ACA。而一项研究发现 与更高的付款相关的PCP预约时间的增加，几乎没有证据表明 政策对实际使用率、临床结果或总支出的影响。尽管证据有限， 2015年，大多数州恢复到2013年前的医疗补助支付水平，而16个州继续支付 增加。我们将研究PCP付款变化与三种类型的结果之间的关联：1) 门诊护理，包括初级保健医生就诊和哨兵质量措施；2)临床事件，包括紧急情况 科室就诊、可预防的住院和死亡率；以及3)医疗总支出和组成部分。 我们的初步分析将使用低收入受益人(2011年N=148万)的联邦医疗保险索赔数据 2011-2017年与提供者以及个人和地区一级特征的补充数据相联系。我们会 使用具有固定效应(人内)估计的准试验性差分设计 比较(1)符合双重资格的人与联邦贫困水平100%的收入(≤)的方法 支出增加(政策干预组)，(2)低收入控制组(101-135%) Fpl)居住在相同地理区域但没有支付变化的非双重医疗保险受益人。我们 将检查居住在扩大和没有扩大医疗补助的州的受益人结果的差异，以及 2014年后没有和没有继续增加工资。我们还将使用以下工具进行补充分析 马萨诸塞州所有付款人索赔数据库检查该州所有医疗补助参与者的结果 (有没有医疗保险)。简而言之，我们将使用ACA创造的自然实验和 全面的数据集，可及时提供有关提高提供商对低成本 收入患者，重点关注脆弱的双重符合资格的人。有关这项政策的潜在影响的信息是 由于联邦政府和各州正在继续做出关于 提供商付款政策。

ABSTRACT This project will assess the impact of primary care provider (PCP) payment policy on outpatient care, clinical events, and medical spending. This project focuses on dual-eligible Medicare-Medicaid beneficiaries, as they are among the most costly and clinically vulnerable individuals in both programs and have historically had suboptimal access to care. We will assess the effects of temporary increases in Medicaid payment rates for PCPs in 2013 and 2014 that were mandated by the Affordable Care Act (ACA); this policy increased PCP payments for dual-eligible beneficiaries by up to 25 percent. The intent of the policy was to improve access to primary care for low-income populations, especially given large expected increases in the number of individuals covered by private insurance and Medicaid coverage due to the ACA. While one study found increased PCP appointment availability associated with the higher payments, there is little evidence on the effects of the policy on actual utilization, clinical outcomes, or total spending. Despite the limited evidence, most states returned to pre-2013 Medicaid payment rates in 2015, while 16 states continued the payment increase. We will examine the association between PCP payment changes and three types of outcomes: 1) outpatient care, including PCP visits and sentinel quality measures; 2) clinical events, including emergency department visits, preventable hospitalizations, and mortality; and 3) total and component medical spending. Our primary analyses will use Medicare claims data for low-income beneficiaries (N=1.48 million in 2011) from 2011-2017 linked with supplemental data on providers and individual- and area-level characteristics. We will use a quasi-experimental difference-in-difference design with fixed effects (within-person) estimation approaches to compare (1) dual-eligibles with incomes ≤100% of the federal poverty level (FPL) for whom PCP payments increased (policy intervention group) with (2) a concurrent control group of low-income (101-135% FPL) non-dual Medicare beneficiaries without payment changes who live in the same geographic areas. We will examine variation in outcomes for beneficiaries living in states that did and did not expand Medicaid, and did and did not continue the payment increase after 2014. We will also conduct supplemental analyses using the Massachusetts All-Payer Claims Database to examine outcomes for all Medicaid enrollees in the state (with and without Medicare). In short, we will use the natural experiment created by the ACA and comprehensive datasets to provide timely information on the impact of increasing provider payments for low- income patients, with a focus on vulnerable dual-eligibles. Information on the potential effects of this policy is urgently needed as the federal government and states are continuing to make ongoing decisions regarding provider payment policy.