Medicare Readmissions Reduction Program: Outcomes, Costs, and Inadvertent Effects

 描述(由申请人提供)：再次入院通常发生在老年人中，与不理想的护理和更差的临床结果相关，并大大增加了医疗费用。2012年9月，医疗保险和医疗补助服务中心实施了医院再入院减少计划。这项政策对患有心力衰竭、心肌梗死和肺炎的65岁及以上成年人的30天风险调整后再住院率高于预期的医院进行了经济处罚，截至2015年，慢性阻塞性肺疾病和髋关节和膝关节置换术。2017年将增加冠状动脉旁路移植术。自2012年以来，重新入院率有所下降，但对长期结果和成本的有利影响尚不确定。如果医院改善住院和过渡相关护理，生存率可能会提高，尽管随着医院努力确保出院后临床稳定，住院时间和正规急性后护理的使用可能会增加。相反， 医院可以玩游戏，比如只重新接纳病情最重的患者，用观察期代替再入院，或者将再入院推迟到30天以上。必要的重新入院障碍可能会导致更多的急诊科就诊利用率和更差的存活率。随着医院创建新的护理系统，有利和不利的影响都可能影响到政策不针对的患者。本项目旨在评估该计划对生存、医疗保健利用和医疗保险支付的影响，并考虑潜在的无意影响。首先，该项目将评估该政策如何影响受益人在住院后六个月内的生存，这一结果对患者很重要。其次，该项目将评估30天的再住院率、医院和急诊后护理的利用率以及医疗保险的支付情况。最后，分析将检查医院的游戏以及对政策未针对的人群的溢出效应。方法将涉及使用医疗保险管理数据来衡量从政策实施前后的临床和经济结果的变化，使用中断的时间序列设计。为了以政策制定者和利益相关者易于理解的格式呈现结果，分析将在模拟中使用模型的估计值，这些模型预测有和没有HRRP的结果。最后，由于医院可能会根据风险收入的百分比做出不同的反应，我们将根据每家医院在医疗保险患者中的份额或每家医院的罚款金额来检查不同医院的影响是否不同。

 DESCRIPTION (provided by applicant): Readmissions occur commonly among the elderly, are associated with suboptimal care and worse clinical outcomes, and contribute substantially to healthcare costs. In September 2012, the Centers for Medicare and Medicaid Services implemented the Hospital Readmissions Reduction Program. The policy financially penalizes hospitals with higher-than-expected 30-day risk-adjusted readmission rates for adults age 65 and older with heart failure, myocardial infarction, and pneumonia, and, as of 2015, chronic obstructive pulmonary disease and arthroplasty of the hip and knee. Coronary artery bypass grafting will be added in 2017. Readmission rates have declined since 2012 but favorable effects on long-term outcomes and costs are not assured. Survival could improve if hospitals improve inpatient and transition-related care, although length of stay and use of formal post-acute care could rise as hospitals strive to ensure clinical stability after discharge. Conversely, hospitals could engage in gaming, such as readmitting only the sickest patients, substituting observation stays for readmissions, or postponing readmissions beyond 30 days. Barriers to necessary readmission could lead to greater utilization of emergency department visits and worse survival. As hospitals create new systems of care, both favorable and unfavorable effects could affect patients not targeted by the policy. This project seeks to evaluate the Program's effects on survival, healthcare utilization, and payments by Medicare, and to consider potential inadvertent effects. First, the project will evaluate how the policy has influenced beneficiaries' survival during the six months after hospitalization, an outcome important to patients. Second, the project will evaluate 30-day readmission rates, utilization of hospital and post-acute care, and payments by Medicare. Finally, the analysis will examine gaming by hospitals and spillover effects for populations not targeted by the policy. Methods will involve using Medicare administrative data to measure changes in clinical and economic outcomes from before to after policy implementation, using an interrupted time-series design. To present results in formats that are easy for policymakers and stakeholders to understand, the analysis will use estimates from the models in simulations that predict outcomes with and without the HRRP. Lastly, because hospitals may respond differently based on the percent of revenue at risk, we will examine whether effects differ across hospitals according to each hospital's share of patients with Medicare insurance or each hospital's penalty size.