Natural Experiment of Value-Based Incentives for Preventive Services

描述（由申请人提供）：财政激励措施可以是影响医疗保健行为的有力工具。文献表明，面临高水平的费用分摊的患者比费用分摊较少的患者对预防服务的使用率低，但很少有儿童研究，只有有限数量的研究表明，消除费用分摊增加了预防的使用。这种保险利益设计与临床目标的一致性，也就是基于价值的保险设计（VBID），是最近的《患者保护和平价医疗法案》（ACA）的核心特征。ACA要求所有健康保险计划消除高价值预防服务的费用分摊，包括美国预防服务工作组（USPSTF）和疾病控制和预防中心（CDC）自2011年以来推荐的服务; ACA，但是，豁免现有的雇主赞助（即，集团）保险计划从这些政策，只要计划不作出重大改变，他们的利益或价格。因此，在这些“祖父”计划中的个人继续面临同样的预防保健费用分摊。我们将利用这一自然实验来研究取消年度健康访问和免疫接种的费用分摊对儿童和青少年（21岁以下）的影响。参加团体健康保险计划而没有费用分摊变化的个人和USPSTF不推荐的测试提供了并行的比较信息。利用MarketScan数据库和Kaiser Permanente的数据，该项目将研究ACA强制医疗保险政策变化对我们结果的早期临床和经济影响：目标1）办公室就诊率;目标2）免疫接种;目标3）总医疗支出。我们的数据包含有关保险福利，个人特征，免疫接种，临床事件和医疗支出的详细，全面的信息。研究样本包括具有一系列基线费用分摊金额和费用分摊变化时间的受试者。我们的主要分析将集中在人内变化（固定效应估计），并将调整丰富的人口统计学，临床和系统特征。有了数百万人年的数据，我们将有足够的能力检测到我们结果中甚至很小的变化。 公共卫生相关性：这项研究将研究为参加团体健康保险计划的儿童和青少年提供免费健康访问和免疫接种的影响。最近的《病人保护和平价医疗法》要求团体保险计划取消这些类型的预防服务的费用分摊，但将许多现有计划排除在新规定之外。换句话说，有超过1亿美国人的ACA规则有关预防服务不适用，因为他们参加了现有的团体健康保险计划与“祖父”的地位。此外，尽管为儿童和青少年提供免费预防服务在直觉上很有吸引力，但目前尚不清楚取消费用分摊是否会改善预防服务的可及性，提高免疫接种率，或影响整体医疗支出。这项工作将为国家卫生政策决定和正在进行的提高护理质量和效率的努力提供信息。

DESCRIPTION (provided by applicant): Financial incentives can be powerful tools to influence health care behavior. The literature suggests that patients faced with high levels of cost-sharing have lower use of preventive services than patients with less cost-sharing, but there are few studies in children and only a limited number of studies in any population demonstrating that the elimination of cost-sharing increases use of prevention. This alignment of insurance benefit design with clinical goals, aka value-based insurance design (VBID), is a central feature of the recent Patient Protection and Affordable Care Act (ACA). The ACA requires that all health insurance plans eliminate cost-sharing for high value preventive services including those services recommended by the US Preventive Services Task Force (USPSTF) and the Centers for Disease Control and Prevention (CDC) as of 2011; the ACA, however, exempts existing employer-sponsored (i.e., group) insurance plans from these policies provided that the plans do not make major changes in their benefits or prices. Thus, individuals within these "grandfathered" plans continue to face the same cost-sharing for preventive care. We will exploit this natural experiment to examine how the elimination of cost-sharing for annual wellness visits and immunizations affects children and adolescents (age up to 21 years). Individuals enrolled in group health insurance plans without cost-sharing changes and tests not recommended by the USPSTF provide concurrent comparative information. Using data from the MarketScan Databases and from Kaiser Permanente, the project will examine the early clinical and economic effects of this ACA-mandated health insurance policy change on our outcomes: Aim 1) office visit rates; Aim 2) immunizations; and Aim 3) total medical spending. Our data contain detailed, comprehensive information on insurance benefits, individual characteristics, immunizations, clinical events, and medical spending. The study sample includes subjects with a range of baseline cost-sharing amounts and in the timing of cost-sharing changes. Our primary analyses will focus on within-person changes (fixed effects estimation), and will adjust for a rich set of demographic, clinical, and system characteristics. With several million person-years of data, we will have adequate power to detect even small changes in our outcomes. PUBLIC HEALTH RELEVANCE: This study will examine the effects of providing free wellness visits and immunizations to children and adolescents enrolled in group health insurance plans. The recent Patient Protection and Affordable Care Act requires that group insurance plans eliminate cost-sharing for these types of preventive services, but exempts many existing plans from the new rules. In other words, there are over one hundred million Americans for whom the ACA rules concerning preventive services do not apply because they are enrolled in existing group health insurance plans with "grandfather" status. Moreover, although providing free preventive services for children and adolescents is intuitively appealing, it is unclear whether th elimination of cost-sharing will improve access to preventive services, increase immunization rates, or affect overall medical spending. This work will inform national health policy decisions and ongoing efforts to improve the quality and efficiency of care.