Exploring Medicare Provider Networks: Implications for Adoption of CER Findings

摘要 如果比较有效性研究(CER)要在不妥协的情况下减少卫生支出增长 健康结果，提供者将需要采取长期的成本节约策略，这些策略被确定为没有 效果不如成本更高的临床策略。了解医疗保险提供者如何建立“虚拟”网络 在考虑旨在促进医疗改革的时候，影响医疗费用和内容可能是重要的 使用低成本、高效率的医疗服务。 我们建议确定决定或影响使用节省成本但有效的临床治疗的因素。 战略。我们还建议调查医疗保险提供者网络(虚拟或社交)的影响 网络)及其关于提供护理的成本和内容(例如，是否基于证据的做法)的结构。 我们的具体目标是：1)确定供需因素预测提供商采用的程度 成本节约的循证发现，2)分析提供商网络结构的差异和影响 关于循证实践和护理成本的使用，3)估计潜在的医疗保险支出节省 基于实施这些发现的政策(可能通过使用支付或医疗改革，如 捆绑支付或ACO)。 我们的分析将基于2005年至2010年A部分和B部分的完整Medicare索赔文件 D部分，2006年至2010年。具体地说，我们将把这些目标应用于慢性阻塞性肺疾病患者的治疗 稳定型心绞痛与冠状动脉支架血管重建术前后的循证研究 (2007年的勇气试验)的出版支持了医疗管理的初步使用。我们会 从Medicare索赔文件中确定以下时间段之前和之后的相关队列 发表，并确定预测提供者实践从支架再血运重建术改变的因素 给医疗管理中的数据。我们将根据人口统计和患者水平的特征进行控制， 调查生态和供应决定因素，并调查不同地理位置和患者的差异 亚群，如妇女、少数民族和糖尿病患者。接下来，我们将确定提供商网络 在医疗保险数据中对慢性稳定型心绞痛的护理，并探索提供者网络结构 影响所提供护理的成本或内容(是否符合循证做法)。我们会 探索不同地理位置的网络结构是否存在差异，以及这是否部分解释了这种差异 在实践中，地区之间的差异和成本。我们将确定如何将我们的发现整合到 医疗改革政策要么优化我们认为是低成本但有效医疗保健决定因素的因素，要么 鼓励形成高效的提供商网络。最后，我们将根据以下数据估计潜在的联邦医疗保险节省 在这些政策上。

Abstract If comparative effectiveness research (CER) is to reduce health expenditure growth without compromising health outcomes, providers will need to adopt long-term cost-saving strategies that are identified as being no less effective than higher-cost clinical strategies. Understanding how provider "virtual" networks for Medicare influence the cost and content of care may be important when considering health reforms designed to promote the use of lower-cost effective medical care. We propose identifying factors that determine or influence the use of cost-saving yet effective clinical strategies. We further propose investigating the influence of Medicare provider networks (virtual or social networks) and their structure on the cost and content (e.g., evidence-based practices or not) of care provided. Our specific aims are to: 1) determine the extent to which supply and demand factors predict provider adoption of cost-saving evidence-based findings, 2) analyze provider network structure for differences in and influence on the use of evidence-based practices and costs of care, 3) estimate potential Medicare expenditure savings based on policies implementing these findings (perhaps through the use of payment or health reforms such as bundled payments or ACOs). We will base our analysis on the complete Medicare claims files for Parts A and B from years 2005 to 2010 and Part D from 2006 to 2010. Specifically, we will apply these aims to the treatment of patients with chronic stable angina and the use of revascularization with coronary stents before and after evidence-based findings (the COURAGE trial in 2007) were published supporting the initial use of medical management. We will identify the relevant cohort from the Medicare claims files for the time period before and after the time of publication, and identify factors that predicted a change in provider practices from revascularization with stents to medical management in the data. We will control for demographic and patient-level characteristics, investigate ecological and supply determinants, and investigate differences across geographies and patient sub-populations such as women, minorities, and those with diabetes. Next, we will identify provider networks of care for chronic stable angina in the Medicare data, and explore whether provider network structure influences the cost or content of care provided (concordant with evidence-based practices or not). We will explore whether network structures differ across geographies, and whether this partially explains the difference in practice variation and cost between regions. We will identify ways that our findings might be integrated into health reform policies either to optimize the factors we identify as determinants of low-cost yet effective care or to encourage efficient provider network formation. Finally, we will estimate potential Medicare savings based upon these policies.