The Effect of Reduction and Standardization of Reimbursements in the VA Fee-Basis Program: Impact on Quality of Care and Health Outcomes

许多参加VHA的退伍军人需要透析，他们从非VA透析获得这项服务 供应商。从历史上看，对非退伍军人透析提供者的补偿非常不稳定，最高可达 大约是统一医疗保险报销率的3倍。2010年，VHA标准化并减少了透析 报销至约130%的联邦医疗保险费用时间表，以遏制不断上涨的费用基础 透析护理的支出。退伍军人管理局在2013年进一步精简了非退伍军人管理局的透析护理支出，发布了 国家透析合同，以确保更有效地确定和偿还透析提供者 对退伍军人来说。向非VA透析提供者支付费用的新机制有望降低“透析费用” 支出减少50%，但如果支付政策不利，实现的成本节约可能无法实现 影响向退伍军人提供的护理质量。几乎没有证据来指导这些努力，而现在， 比以往任何时候都更需要严格的评估，以了解这些外包支付模式是如何 透析服务改变了透析护理的提供模式，并了解政策变化可能 改变了对退伍军人的透析服务质量。 现在，比以往任何时候都更需要进行严格的评估：(1)了解这些支付模式如何 外包透析服务影响透析护理提供的模式；(2)确定如何改变 购买政策影响了退伍军人获得护理的机会和他们的体验质量；以及(3)提供洞察力 关于如何改善为退伍军人提供的外包透析护理。这项研究将估计 这些政策变化对退伍军人的影响，并确定是否存在地理上的偶然性、价值 基于从非退伍军人管理局购买透析服务的模式可以改善总体结果 需要透析的退伍军人所经历的。 为了达到我们提案的目标，我们汇集了一项多站点、多学科的研究 适合进行这项研究的团队。我们使用了来自美国退伍军人管理局的大量数据集 肾脏数据系统，以及跨越十年患者护理(2006-2015)的医疗保险。为了揭开 政策对透析相关住院和死亡率的因果影响，我们估计- 比较退伍军人在任职前的平均政策差异的差异模型 在非退伍军人医院接受透析的患者(治疗组)和正在接受透析治疗的患者 在退伍军人管理局拥有的设施中进行透析(对照组)。这项研究的发现将提供亟需的证据 了解退伍军人管理局非退伍军人护理的支付和购买政策对 透析护理的质量和退伍军人的结局。此外，结果将为未来的政策和做法提供信息。 用于购买透析护理以及管理退伍军人选择法案的实施。通过 本研究旨在提高虚拟现实的质量和可及性，为虚拟现实战略的未来发展指明方向 医疗保健服务在优化价值的同时，符合VHA卓越蓝图的目标。

Many Veterans enrolled in the VHA who require dialysis receive this service from non-VA dialysis providers. Historically reimbursement to non-VA dialysis providers was highly variable, with payments up to roughly 3-times the uniform Medicare reimbursement rate. In 2010 the VHA standardized and reduced dialysis reimbursements to about 130 percent of the Medicare fee schedule in order to curb rising Fee Basis expenditures for dialysis care. The VA further streamlined non-VA dialysis care payments in 2013 by issuing national dialysis contracts to ensure a more efficient process of identifying and reimbursing dialysis providers for Veterans. The new payment mechanism to non-VA dialysis providers was expected to reduce “fee dialysis” expenditures by 50%, but the realized cost savings may not materialize if the payment policy adversely impacts the quality of care provided to Veterans. There was little evidence to guide these efforts and now, more than ever, rigorous evaluation is needed to understand how these payment models for outsourced dialysis services changed the patterns of dialysis care delivery and to understand how policy changes may have altered the quality of dialysis services to Veterans. Now, more than ever, rigorous evaluation is needed to: (1) understand how these payment models for outsourced dialysis services affect the pattern of dialysis care delivery; (2) determine how changes in purchasing policy affected Veterans' access to care and the quality of their experience; and (3) provide insight about how the delivery of outsourced dialysis care for Veterans can be improved. This study will estimate the impact of these policy changes on Veterans and to determine whether a geographically contingent, value based model for purchasing dialysis services from non-VA vendors could improve the overall outcomes experienced by Veterans requiring dialysis. In order to address the Aims of our proposal, we bring together a multi-site, multi-disciplinary research team that is aptly suited to conduct this study. We employ a rich array of data sets from the VA, United States Renal Data System, and Medicare that span a decade of patient care (2006-2015). In order to unravel the causal effect of the policy on dialysis-related hospitalization and mortality, we estimate a difference-in- difference model that compares the average pre-post policy differences in the outcomes between Veterans that are undergoing dialysis in non-VA facilities (treatment group) and their counterparts that are undergoing dialysis in VA-owned facilities (control group). Findings from this study will provide much needed evidence to understand the extent to which VA's payment and purchasing policies for non-VA care have impacted the quality of dialysis care and Veterans' outcomes. Furthermore, results will inform future policies and practices for purchasing dialysis care as well as those governing implementation of the Veteran's Choice Act. By informing the future direction of VA strategy, this research seeks to improve the quality and accessibility of health care services while optimizing value and is consistent with VHA Blueprint for Excellence goals.