Evaluating Policies for Improving Surgical Care in the Elderly

描述（由申请人提供）：在美国，每年有超过50,000名医疗保险患者死于住院手术。有证据表明，各供应商之间存在很大差异，这表明还有很大的改进空间。为了改善老年人的外科护理，医疗保险和医疗补助服务中心（CMS）推出了几项政策。然而，这些政策在多大程度上改善了手术结果并降低了手术费用，这是未知的。因此，我们建议对国家医疗保险人群中几种政策选择对手术护理质量和成本的影响进行系统评估。基于这一目标，我们目前的建议有以下目标：目标1。评价CMS改进政策对手术结果的影响。我们将在全国医疗保险人群中进行绩效付费、选择性转诊、捆绑支付和结果反馈的评估。对于每种政策方法，我们将利用自然实验（即过去5年实施的特定计划或政策）。为了评估结果，我们将使用政策明确针对的手术的风险调整死亡率和并发症。为了更好地控制医院病例组合和长期趋势，我们将使用差异中差异方法。目标2。评估这些CMS政策对非靶向手术条件的溢出效应。使用国家医疗保险数据，我们将检查患者接受同一外科医生护理或依赖同一医院资源的非靶向手术的结果。我们将评估这些政策是否会产生有益的溢出效应，或在资源被转移到目标条件时造成意外伤害。目标3。评估这些政策对手术期间医疗保险支付的影响。我们将评估所有可能与并发症和低质量医疗服务相关的医疗保险支付。我们将包括支付给医院、医生、再入院和急症后护理的费用。本研究的结果将促进CMS和其他支付方基于证据的政策制定。随着改善护理的有效政策的实施，手术患者将是本研究的最终受益者。

DESCRIPTION (provided by applicant): Each year in the United States, more than 50,000 Medicare patients die undergoing inpatient surgery. Evidence of wide variations across providers suggests substantial room for improvement. To improve surgical care in the elderly, the Center for Medicare and Medicaid Services (CMS) has launched several policies. However, the extent to which these policies improve outcomes and reduce costs in surgery is unknown. We therefore propose a systematic evaluation of the impact of several policy options on the quality and cost of surgical care in the national Medicare population. With this goal in mind, our current proposal has the following aims: Aim 1. To evaluate the impact of CMS improvement policies on surgical outcomes. We will conduct evaluations of pay-for-performance, selective referral, bundled payment, and outcomes feedback in the national Medicare population. For each policy approach, we will take advantage of a natural experiment (i.e., a specific program or policy implemented in the last 5 years). To assess outcomes, we will use risk-adjusted mortality and complications for the procedures specifically targeted by the policy. To better control for hospital case-mix and secular trends, we will use a difference-in-difference methodology. Aim 2. To evaluate the spillover effects of these CMS policies on untargeted surgical conditions. Using national Medicare data, we will examine outcomes for untargeted procedures for which patients receive care from the same surgeons or depend on the same hospital resources. We will assess whether these policies resulted in beneficial spillover effects or caused unintended harm as resources were diverted to the targeted conditions. Aim 3. To evaluate the impact of these policies on Medicare payments around the surgical episode. We will evaluate Medicare payments for the full range of services that can be linked to complications and poor quality care. We will include payments to the hospital, physicians, readmissions, and post-acute care. The results of this study will facilitate evidence-based policymaking by CMS and other payers. As effective policies for improving care are implemented, surgical patients will be the ultimate beneficiaries of this research.