Natural Experiments to Understand Plan and Provider Behavior in an Era of Accountability

摘要 向医疗保险提供者和计划支付费用对老年人的健康和 已禁用。按服务收费的支付方式受到了正确的批评，因为它激励了过度和 提供可能有害的护理，并通过将补偿挂钩而干扰健康的生产 到特定的输入。为了建立更大的灵活性和责任感，医疗保险越来越多地将 能够管理护理的实体的财务风险-首先是Medicare Advantage(MA)计划中的私人计划 以及最近通过传统Medicare(TM)中的替代支付模式(APM)直接向提供商提供的服务。在……里面 在这两种模式下，额外的付款调整都与质量指标的表现挂钩。这些方法 整合融资和提供护理创造机会，改善患者护理，但经验性的 学习一直是具有挑战性的。MA计划的优点和MA的相对绩效的证据 而APM在很大程度上是观察性的，在分析患者经历和健康结果方面受到限制。 此外，风险签约在很大程度上依赖于风险调整，以配置计划或提供商业绩，并使 资源与患者群体的需求相适应，但风险调整的充分性一直不佳 描述。该项目将通过利用自然实验和新数据来做出实质性贡献 了解计划和提供者对付款激励的反应及其对患者和付款的影响 系统设计。该项目包括三个目标。首先，我们将使用自然实验来比较性能 在MA和TM以及每个系统的不同变种之间。MA与TM Will的准随机化来源 包括各州和县之间在MA风险敞口以及从Medicaid向Dual过渡方面的差异 年龄在65岁时符合MA暴露程度高或低的条件。我们将基于以下内容探索效果异构性 MA(例如，按计划类型)和TM(例如，按APM活动)配置的地理变化。第二，我们 将评估熟练护理设施(SNF)中急性后护理的边际价值以及激励措施的影响 在不同的支付模式(包括TM、MA和APM)中更改急性发作后住院时间对患者结果的影响。 急性后护理是MA和APM中密集活动的一个领域，它提供了对提供者机构的洞察。 办法将利用与逗留期限有关的SNF报销和共同保险中的不连续 以及自然地将患者随机分配给医院的理疗师。第三，我们将确定在何种程度上 哪些风险调整后的MA-TM结果差异反映了绩效差异与剩余风险选择 并评估风险调整方法的充分性。我们将使用我们第一个目标中的策略来比较MA- 自分类种群与准随机种群的TM性能差异。调查结果将表征 增值竞争的前景或预期支付系统带来的意外后果 并将对质量分数的有效性产生重要影响。因此，该项目将为 通过支付系统和绩效监测改善健康状况的证据和见解。

ABSTRACT Payment to providers and plans in Medicare has far-reaching implications for the health of the elderly and disabled. The fee-for-service basis for payment has been rightly criticized for incentivizing excessive and potentially harmful provision of care and for interfering with the production of health by linking reimbursement to specific inputs. To establish greater flexibility and accountability, Medicare has increasingly transferred financial risk to entities that can manage care—first to private plans in the Medicare Advantage (MA) program and more recently to providers directly in alternative payment models (APMs) in traditional Medicare (TM). In both models, additional payment adjustments are tied to performance on quality measures. These approaches to integrating the financing and delivery of care create opportunities to improve patient care, but empirical study has been challenging. Evidence on the merits of the MA program and the relative performance of MA and APMs has been largely observational and limited in analysis of patient experiences and health outcomes. In addition, risk contracting relies heavily on risk adjustment to profile plan or provider performance and to align resources with the needs of patient populations, but the adequacy of risk adjustment has not been well described. This project will make substantial contributions by leveraging natural experiments and new data to understand plan and provider responses to payment incentives and their implications for patients and payment system design. The project includes three aims. First, we will use natural experiments to compare performance between MA and TM and different variants of each system. Sources of quasi-randomization to MA vs. TM will include differences across state and county borders in MA exposure and transitions from Medicaid to dual eligibility at age 65 in areas of high or low MA exposure. We will explore effect heterogeneity based on geographic variation in the configuration of MA (e.g., by plan type) and TM (e.g., by APM activity). Second, we will assess the marginal value of post-acute care in skilled nursing facilities (SNFs) and effects of incentives to alter post-acute length of stay on patient outcomes in different payment models, including TM, MA, and APMs. Post-acute care is an area of intense activity in MA and APMs that offers insights into provider agency. Approaches will make use of discontinuities in SNF reimbursement and coinsurance related to length of stay and natural randomization of patients to physical therapists in hospitals. Third, we will determine the extent to which risk-adjusted MA-TM differences in outcomes reflect performance differences vs. residual risk selection and assess the adequacy of risk-adjustment methods. We will use strategies from our first aim to compare MA- TM performance differences in self-sorted vs. quasi-randomized populations. Findings will characterize the prospects for value-enhancing competition or unintended consequences from prospective payment systems and will have important implications for the validity of quality scores. Thus, the project will provide foundational evidence and insights for improving health through payment systems and performance monitoring.