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

描述（由申请人提供）：候选人和职业发展计划。 Michael McWilliams博士是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过多学科培训，并坚定地致力于对患有慢性病的老年人进行卫生服务研究。他以前的研究评估医疗保险覆盖对老年无保险成年人的医疗保健和健康结果的影响已经得到了全国的认可，他未来的研究将集中在改善医疗保险计划中老年人的护理系统。他的职业发展计划被整合到他提出的研究中，包括结构化的培训课程和与高级教师的学徒制，并在老龄化研究和哈佛的临床和转化科学中心，哈佛催化剂的综合课程。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，并支持他作为一名创新研究者向独立过渡，他将多个学科结合起来进行研究，对国家卫生政策和美国老年人的健康产生重要影响。 体制环境。哈佛医学院卫生保健政策系为McWilliams博士提供了一个丰富的环境，以从事他的研究工作和发展他的职业生涯。该系在发展初级教师的职业生涯方面有着悠久而成功的记录。他将得到John Ayanian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，其中包括经济学，公共政策，临床医学和老年学，在老龄化，统计学和商业临床研究借鉴。更大的哈佛社区和他的咨询委员会将促进新的合作和未来的研究方向，以及通过催化剂和老龄化相关的研讨会提供额外的培训资源。 研究项目：改革医疗保险：受益选择，计划支付和负责任的护理。随着人口老龄化、慢性病负担的增加以及医疗保健成本以不可持续的速度增长，医疗保险计划面临着巨大的挑战：改善健康结果，同时减缓患有慢性病的老年人的医疗支出。在医疗保险优势（MA）中，受益人面临着管理式医疗计划的复杂选择，计划支付的风险调整不足导致了选择更健康受益人的不正当激励，而不是专注于有效的慢性病护理。除了这种福利损失和MA中的浪费性竞争之外，传统医疗保险（TM）的交付系统是分散的，因为按服务付费的方式几乎没有激励提供者协调护理或采用创新的护理管理方法。医疗保险计划的成功改革可能需要协调一致的努力，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者和计划之间的健康竞争。 因此，拟议的研究项目将利用国家索赔和对患者和提供者的调查数据，为制定改善美国老年人护理系统的政策提供信息，并在医疗保险中实现更大的价值。首先，将审查受益人登记决定，以确定过于复杂的选择是否会导致选择较差的选择，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和增加慢性病患者的入组和保留来做出反应。第三，该项目将衡量当地交付系统的结构准备，以形成综合的责任护理组织（ACO），评估在全国范围内这种准备的异质性，并研究医生的做法之间的整合如何与医疗保健计划中的老年人的护理，护理质量和医疗保健支出的碎片。 这项拟议中的卫生服务研究将对美国老年人的临床护理产生重要影响。对目标1和2的分析将确定，按照目前的结构扩大MA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，通过复杂的选择指导老龄化受益人，并改进支付公式，以促进知情决策和有效竞争。目标3的研究结果将描述交付系统结构准备的异质性，以形成综合的ACO，相应的需要将不同的准备阶段与不同的激励措施相匹配，以改善交付和支付系统，并通过新的支付来提高医疗保险的价值。 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发展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。比森职业发展奖将大大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，以及他作为老龄化研究国家领导者作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.