Evaluating Pay for Performance and its Design: Evidence from Nursing Homes

描述（由申请人提供）：提高4000多万65岁以上美国人的护理质量是国家的主要优先事项，特别是在人口老龄化的情况下。在过去的几十年里，为了提高老年人的护理质量而采取了许多政策，取得了不同程度的成功，但医疗保健支付在很大程度上是一个尚未开发的、但潜在的强大政策工具，可以提高护理质量。然而，最近，支付方在医院、医生、养老院和家庭保健提供者的绩效薪酬计划的开发和实施上投入了大量资源。尽管对绩效薪酬的热情和广泛采用，但将此类计划与质量改进联系起来的经验证据却出奇地少。目前的证据留下了许多悬而未决的问题，这些问题不仅涉及绩效薪酬的有效性，还涉及这些计划的设计和实施如何影响质量的提高。随着国家致力于提高护理质量，修改现行的支付制度以奖励高质量的护理将是最重要的政策工具之一。为了促进这些政策的制定和成功，至关重要的是要更好地了解按绩效付费的有效性，以及对提供高质量医疗服务影响最大的按绩效付费方案的要素。本研究的总体目标是评估绩效薪酬与养老院提供高质量护理之间的关系。几十年来，养老院一直被低质量的护理和失败的尝试所困扰。这项提议的研究旨在利用迄今为止全国规模最大的绩效薪酬实验之一：最近一些州医疗补助机构采用了养老院的绩效薪酬。由于医疗补助计划的养老院绩效薪酬计划是在州一级实施的，因此它们在计划设计和实施时间上各不相同。这为评估绩效薪酬及其设计提供了独特而及时的机会。本研究利用1999年至2009年美国所有养老院的最低数据集、医疗保险索赔和在线调查、认证和报告（OSCAR）数据库中的全国数据，考察了一些州实施绩效薪酬时养老院护理质量的变化，并控制了未实施绩效薪酬的州的长期趋势。具体而言，本项目考察：1)绩效薪酬是否通过改变临床质量措施、可避免住院率、人员配备水平和缺陷数量来提高护理质量；2)绩效薪酬的设计如何影响护理质量的改善，检查每个项目中财政激励的大小和使用的措施类型的差异；(3)绩效薪酬对医疗机构间护理差异的影响。本研究的结果将对现有的绩效薪酬文献做出重大贡献，并为政策制定者和保险公司提供有关绩效薪酬设计和实施的重要信息。

DESCRIPTION (provided by applicant): Improving quality of care for the over 40 million Americans over the age of 65 is a major national priority, particularly as the population ages. While numerous policies have been adopted to improve quality of care for older adults over the past several decades-with varying degrees of success-health care payment has been a largely untapped but potentially powerful policy tool to improve quality of care. Recently, however, payers have invested significant resources in the development and implementation of pay-for-performance programs for hospitals, physicians, nursing homes, and home health providers. Despite the enthusiasm for and widespread adoption of pay for performance, the empirical evidence linking such programs to quality improvement is surprisingly thin. Current evidence leaves many unanswered questions concerning not only the effectiveness of pay-for-performance, but how the design and implementation of these programs affect quality improvement. As the country focuses on improving quality of care, modifying the current payment system to reward high-quality care will be one of the most important policy tools. To improve the development and success of these policies, it is crucial to gain a better understanding of the effectiveness of pay-for- performance and the elements of pay-for-performance programs that most influence provision of high-quality care. The overall objective of this study is to assess the relationship between pay-for-performance and the delivery of high-quality care in the setting of nursing homes. Nursing homes have been plagued for decades by low quality of care and failed attempts to substantially improve quality. The proposed study seeks to take advantage of one of the largest national experiments in pay-for-performance to date: the recent adoption of nursing home pay-for-performance by a number of state Medicaid agencies. Because Medicaid's nursing home pay-for-performance programs are implemented at a state level, they vary in program design and timing of implementation. This provides a unique and timely opportunity to evaluate pay-for-performance and its design. Using national data on all US nursing homes from the Minimum Data Set, Medicare claims, and the Online Survey, Certification, and Reporting (OSCAR) database from 1999 to 2009, this study examines changes in the quality of nursing home care when some states implemented pay for performance, controlling for secular trends in states without pay for performance. Specifically, this project examines: 1) whether pay- for-performance improves quality of care through changes in clinical quality measures, avoidable hospitalization rates, staffing levels, and number of deficiencies; 2) how the design of pay-for-performance affects improvement in quality of care, examining differences in the size of financial incentives and types of measures used in each program; and 3) the effect of pay-for-performance on disparities in care between facilities. The results from this study will contribute significantly to existing literature on pay-for-performance and provide vital information to policy makers and insurers regarding the design and implementation of pay-for- performance. PUBLIC HEALTH RELEVANCE: Nursing homes have been plagued for decades by low quality of care and failed attempts to substantially improve quality. Improving quality of care in nursing homes is a national priority. This project tests the effect of pay-for-performance on quality of care in nursing homes and will directly inform future efforts to improve quality of care for nursing home residents and design more effective pay-for-performance programs.