Reforming Medicare: Beneficiary Choice, Plan Payment, and Accountable Care

描述(由申请者提供)：应聘者和职业发展计划。J.Michael McWilliams，医学博士，哈佛医学院卫生保健政策助理教授，在内科、卫生政策和研究方法方面接受多学科培训，并致力于对患有慢性病的老年成年人进行卫生服务研究。他之前的研究评估了联邦医疗保险覆盖范围对老年未参保成年人的医疗保健和健康结果的影响，已得到全国认可，他未来的研究将专注于改善联邦医疗保险计划中老年成年人的护理系统。他的职业发展计划被整合到他提出的研究中，包括有组织的培训课程和与资深教师的学徒培训，并以老龄化研究和哈佛临床与转化科学中心-哈佛催化剂-的全面课程为特色。这些培训活动与他的研究相结合，将加深他对卫生经济学、卫生保健组织、统计学以及老龄化的临床和社会方面的理解，促进富有成效的合作，并支持他向独立的转变，成为一名将多个学科结合在一起的创新研究人员，以产生对国家卫生政策和美国老年人健康具有重要影响的研究。 制度环境。哈佛医学院卫生保健政策系为麦克威廉姆斯博士提供了一个丰富的环境，让他继续从事研究工作，发展他的职业生涯。在发展初级教员的职业生涯方面，该系有着长期而成功的记录。他将得到约翰·阿亚尼安博士和托马斯·麦奎尔博士的出色指导以及充足的计算资源的支持。他将从他的导师和高级合作者的广泛学科中吸取教训，包括经济学、公共政策、临床医学和老年学、老龄临床研究、统计学和商学。更大的哈佛社区和他的咨询委员会将为未来的研究促进新的合作和方向，并通过催化剂和与老龄化有关的研讨会提供额外的培训资源。 研究项目：改革医疗保险：受益人选择、计划支付和责任医疗。随着人口老龄化、慢性病负担的增加以及医疗费用以不可持续的速度增长，联邦医疗保险计划面临着巨大的挑战：在减缓越来越多患有慢性病的老年人口的医疗支出的同时，改善医疗结果。在Medicare Advantage(MA)中，受益人面临管理保健计划之间的复杂选择，计划支付的风险调整不充分导致了选择更健康的受益人而不是专注于有效的慢性病护理的错误激励。除了MA中的这种福利损失和浪费性竞争之外，传统Medicare(TM)的交付系统也是支离破碎的，因为按服务付费几乎没有为提供者提供协调护理或采用创新护理管理方法的激励。医疗保险计划的成功改革可能需要协调努力，重新设计交付和支付系统，重组市场，以支持患者的知情选择以及提供商和计划之间的良性竞争。 因此，拟议的研究项目将使用国家索赔和关于患者和提供者的调查数据，为制定政策提供信息，以改善美国老年人的护理系统，并在医疗保险中实现更大的价值。首先，将审查受益人的投保决定，以确定过于复杂的选择是否会导致选择较差的选项，特别是在认知障碍的成年人中。其次，该项目将评估最近改进的风险调整方法，以确定MA计划是否通过减少适得其反的选择行为以及增加慢性病患者的登记和保留来做出回应。第三，该项目将衡量当地提供系统的结构准备情况，以形成综合的责任护理组织(ACOS)，评估全国范围内这种准备情况的异质性，并检查医生实践之间的整合如何与联邦医疗保险计划中老年成年人的护理、护理质量和医疗支出的碎片化相关。 这项拟议的医疗服务研究将对美国老年患者的临床护理产生重要影响。目标1和目标2的分析将确定，按照目前的结构扩大医疗保险的政策是否可能增加医疗保险的价值，或者是否需要进行更根本的改革，以引导老年受益人通过复杂的选择并完善支付公式，以促进明智的决策和有效的竞争。AIM 3的调查结果将表征交付系统的结构准备情况的异质性，以形成综合ACO，相应地需要将准备就绪的不同阶段与不同的激励相匹配，以同步改进交付和支付系统，以及通过向综合交付系统进行新的支付，实现医疗保险更大价值的潜力。 公共卫生相关性：这项拟议的研究有可能影响国家卫生政策的制定和医疗保险人口的先进护理系统，因此可能对许多美国老年人的临床结果产生重大影响。比森职业发展奖将极大地提高麦克威廉姆斯博士实现他提出的短期培训和研究目标的能力，以及他作为全国老龄化研究领先者做出持久贡献的长期职业目标。

DESCRIPTION (provided by applicant): Candidate and Career Development Plan. J. Michael McWilliams, MD, PhD is an Assistant Professor of Health Care Policy at Harvard Medical School with multidisciplinary training in internal medicine, health policy, and research methods and a strong commitment to health services research on aging adults with chronic conditions. His previous research assessing the effects of Medicare coverage on health care and health outcomes for aging uninsured adults has been nationally recognized, and his future research will focus on improving systems of care for elderly adults in the Medicare program. His career development plans are integrated into his proposed research, include structured training sessions and apprenticeships with senior faculty, and feature a comprehensive curriculum in aging research and Harvard's Clinical and Translational Sciences Center, the Harvard Catalyst. These training activities, in concert with his research, will deepen his understanding of health economics, health care organizations, statistics, and the clinical and social aspects of aging, foster productive collaborations, and support his transition to independence as an innovative investigator who combines multiple disciplines to produce research with important implications for national health policy and the health of elderly Americans. Institutional Environment. The Department of Health Care Policy at Harvard Medical School offers a rich environment for Dr. McWilliams to pursue his research endeavors and develop his career. The Department has a long and successful track record of developing the careers of its junior faculty. He will be supported by the excellent mentorship of Dr. John Ayanian and Dr. Thomas McGuire and by ample computational resources. He will draw from the broad range of disciplines of his mentors and senior collaborators, which include economics, public policy, clinical medicine and gerontology, clinical research in aging, statistics, and business. The larger Harvard community and his advisory committee will foster new collaborations and directions for future research, as well as provide additional training resources through the Catalyst and aging-related seminars. Research Project: Reforming Medicare: Beneficiary Choice, Plan Payment, and Accountable Care. With the population aging, burden of chronic disease rising, and health-care costs growing at an unsustainable rate, the Medicare program faces an enormous challenge: to improve health outcomes while slowing medical spending for a growing population of elderly adults with chronic conditions. In Medicare Advantage (MA), beneficiaries face complex choices among managed care plans, and inadequate risk-adjustment of plan payments has led to perverse incentives to select healthier beneficiaries rather than focus on effective chronic disease care. In addition to this welfare loss and wasteful competition in MA, the delivery system in Traditional Medicare (TM) is fragmented, as fee-for-service payment has provided little incentive for providers to coordinate care or adopt innovative methods of care management. Successful reform of the Medicare program will likely require coordinated efforts to redesign the delivery and payment systems and restructure markets to support informed choices by patients and healthy competition among providers and plans. Therefore, the proposed research project will use national claims and survey data on patients and providers to inform the development of policies to improve systems of care for elderly Americans and achieve greater value in Medicare. First, beneficiary enrollment decisions will be examined to determine if overly complex choices lead to the selection of inferior options, particularly among cognitively impaired adults. Second, the project will evaluate recently improved methods of risk-adjustment to determine if MA plans have responded by reducing counterproductive selection behaviors and increasing their enrollment and retention of patients with chronic illnesses. Third, the project will measure the structural readiness of local delivery systems to form integrated Accountable Care Organizations (ACOs), assess the heterogeneity in this readiness across the country, and examine how integration among physician practices relates to fragmentation of care, quality of care, and health care spending for elderly adults in the Medicare program. This proposed health services research will have important implications for the clinical care of aging Americans. Analyses from Aims 1 and 2 will determine if policies to expand MA as currently structured are likely to increase value in Medicare, or if more fundamental reforms to guide aging beneficiaries through complex choices and refine the payment formula are needed to promote informed decisions and efficient competition. Findings from Aim 3 will characterize the heterogeneity in structural readiness of the delivery system to form integrated ACOs, the corresponding need to match different stages of readiness with different incentives to improve the delivery and payment systems in tandem, and the potential for greater value in Medicare through novel payments to integrated delivery systems. PUBLIC HEALTH RELEVANCE: This proposed research has the potential to influence the development of national health policy and advanced systems of care for the Medicare population, and could thus have a substantial impact on the clinical outcomes of many elderly Americans. The Beeson Career Development Award would greatly enhance Dr. McWilliams' ability to achieve the short-term training and research objectives he has proposed as well as his long-term career goal of making lasting contributions as a national leader in aging research.