Value-based Purchasing in Implementation of Depression Care in Community Clinics

到2019年，多达4000万低收入美国人将依赖社区卫生诊所（CHCs）进行初级保健。抑郁症和其他行为健康状况是这一人群疾病负担的主要来源。实施循证行为保健是社区卫生中心的优先领域。本研究的目的是评估价值为基础的采购（VBP）的作用，政策策略，以加强有计划地实施循证护理在社区卫生服务中心。VBP是一种通过将付款与具有预先指定的绩效目标的供应商组织联系起来来促进质量改进的工具。拟议的研究将利用一个独特的VBP计划发起的华盛顿州心理健康整合计划（MHIP）。MHIP实施协作护理模式，这是一个突出的，基于证据的模式，将行为健康护理纳入初级保健。MHIP的多阶段VBP嵌入了几个理想的设计功能，并提供了一个难得的机会，以产生VBP的有效性，以支持实施循证慢性病护理的一般性调查结果。我们将对现有数据进行回顾性分析，这些数据基于来自华盛顿州国王县和皮尔斯县52个社区卫生中心的12,000多名患者的MHIP登记和医疗保健索赔。本研究的目的是评估MHIP VBP对以下方面的影响：1.社区卫生服务中心采用协作式护理; 2.患者结局。我们将根据协作护理的关键护理过程要素在患者事件水平上的CHC表现来衡量采用情况。患者结局包括抑郁症状、住院、急诊室使用和总医疗费用。我们的分析策略将利用自然实验， 将患者滚动入组MHIP。具体而言，我们将比较与VBP前、VBP后和VBP后发生的患者事件相关的结局，同时控制CHCs的持续学习和采用过程。初步数据表明，整体采用低前VBP，随着时间的推移，和CHC的行为反应VBP的激励措施是一致的概念框架的建议研究，大幅改善。这项研究将产生重要的知识，以帮助决策者决定是否使用VBP来加强社区卫生服务中循证护理的实施，以及如何最好地设计VBP以最大限度地发挥其影响。

DESCRIPTION (provided by applicant): As many as 40 million low-income Americans will rely on community health clinics (CHCs) for primary care by 2019. Depression and other behavioral health conditions are a major source of disease burden in this population. Implementation of evidence-based behavioral health care is a priority area for CHCs. The goal of this study is to assess the role of Value-Based Purchasing (VBP), a policy strategy, to enhance planned implementation of evidence-based care in CHCs. VBP is a tool to spur quality improvement by linking payment to provider organizations with pre-specified performance targets. The proposed study will leverage a unique VBP program initiated by the Washington State Mental Health Integration Program (MHIP). MHIP implements the Collaborative Care model, a prominent, evidence-based model to integrate behavioral health care into primary care. MHIP's multi-phase VBP embeds several desirable design features and offers a rare opportunity to produce generalizable findings on the effectiveness of VBP to support implementation of evidence-based chronic care. We will conduct retrospective analysis of existing data based on MHIP registry and health care claims of over 12,000 patients from 52 CHCs in Washington State's King and Pierce Counties. Aims of the study are to assess the effects of MHIP VBP on: 1. Adoption of Collaborative Care by CHCs; and, 2. Patient outcomes. We will measure adoption based on CHC performance of key process-of-care elements of Collaborative Care at the patient-episode level. Patient outcomes include depression symptoms, hospitalization, emergency room use and total health care costs. Our analytical strategy will exploit the natural experiment created by the rolling enrollment of patients into MHIP. Specifically, we will compare outcomes pertaining to patient-episodes that occurred pre-, peri-, and post- VBP while controlling for the continuous learning and adopting processes at CHCs. Preliminary data suggest overall low adoption pre-VBP, substantial improvement over time, and CHC behavioral responses to VBP incentives that are consistent with the conceptual framework of the proposed study. This study will generate critical knowledge to assist policymakers with their decisions on whether to use VBP to enhance implementation of evidence-based care in CHCs and how to best design VBP to maximize its impact.