Estimating Hospital Outcome Quality: Applications to Pay-for-Performance

描述（由申请人提供）：拟议的项目将追求两个主要领域的研究有关的质量衡量和支付政策改革，以提高医疗保健的价值。第一个是关于结果质量和成本的估计的评估和设计，以配置文件的医疗服务提供者的性能。本研究将评估现有的结果性能估计的性能，提出新的估计，并验证这些估计的性能，以配置文件的质量，成本和医院和医生的做法的效率。我将研究的第二个领域是对马萨诸塞州医疗补助（MassHealth）医院绩效工资（P4P）计划的评估。我将测试P4P计划对该计划中激励的领域（孕产妇和新生儿护理，社区获得性肺炎，外科感染预防，儿科哮喘）的质量和成本的影响。我还将评估该计划对种族和民族差异的影响。为了评估结果测量的性能，将构建模拟模型，并设计和实施一系列蒙特-卡罗模拟实验。基本方法如下：假设的提供者被随机分配一个“真实”的结果评分，一个性能改善轨迹，一个患者风险评分，一个样本量，和一个样本量轨迹。然后为每个提供者创建与样本大小成反比的随机冲击。为每家医院创建观察结果评分，作为真实结果质量、患者风险和随机电击的函数。仅使用观察到的结果的信息，真实的结果，然后估计使用候选结果估计和这些估计的性能进行比较。然后，将使用国家医疗保险数据和来自马萨诸塞州的数据，为医院和医生验证这些估计器的性能。为了评估大众健康计划对质量，成本以及种族和民族差异的影响，我将借鉴我以前研究中采用的方法。这将涉及使用面板数据计量经济学技术来测试该计划实施后，马萨诸塞州医院是否提高了质量，降低了大众健康患者的成本。为了检验该计划对差异的影响，我将测试该计划实施后医院内质量差异和医院间质量差异的减少情况。追求我的研究所需的技能和知识将得到一群优秀的导师和一个强大的教育和职业发展计划的支持。我的导师是医疗保健支付和融资，质量测量，组织研究，卫生经济学和比较有效性领域的领导者。此外，我的导师在他们的研究中采用了经济学，政治学，社会学和临床实践的见解和观点，提供了丰富多样的知识环境，我可以作为学员借鉴。在遵循我的职业发展计划，我将提高我的方法和编程技能，学习更多关于负责任的研究行为，获得临床实践和医疗组织的知识，并提出我的研究成果，并在几个国家会议上与同事互动。成功实现我的K01提案目标的研究将具有重要的政策相关性。拟议中的研究将增加我们的知识，在绩效工资和公共质量报告的结果措施的使用，同时也提供了进一步的证据，通过对马萨诸塞州计划的评估，绩效工资的有效性。虽然雄心勃勃，但我的研究成就记录表明，我有能力进行实现这些目标的研究。此外，为K01进行的课程和应用研究将增强我的研究技能，提高我实现这些目标的能力。在与我的导师合作进行这项研究后，我将成为P4P和质量测量领域的研究人员，并将自己定位为这些领域的R01赠款。 公共卫生相关性：拟议的项目有可能产生积极影响的公共卫生，通过创建更准确的估计医疗保健提供者的结果质量和成本，并通过促进医院为基础的绩效付费的影响的理解。这项研究可用于设计支付政策，为医疗保健的价值和质量改进创造更强的激励。

DESCRIPTION (provided by applicant): The proposed project will pursue two major areas of research related to quality measurement and payment policy reform to improve value in healthcare. The first pertains to the evaluation and design of estimators of outcome quality and cost in order to profile the performance of healthcare providers. This research will evaluate the performance of existing estimators of outcome performance, propose new estimators, and validate the performance of these estimators to profile the quality, cost, and efficiency of hospitals and physician practices. The second area of research I will pursue is an evaluation of the Massachusetts Medicaid (MassHealth) hospital-based pay-for-performance (P4P) program. I will test the effect of the P4P program on quality and cost for the areas incentivized in the program (maternity and newborn care, community acquired pneumonia, surgical infection prevention, pediatric asthma). I will also estimate the effect of the program on racial and ethnic disparities. To evaluate the performance of outcome measures, a simulation model will be constructed and a series of Monte-Carlo simulation experiments will be designed and implemented. The basic approach is as follows: hypothetical providers are randomly assigned a "true" outcome score, a performance improvement trajectory, a patient risk score, a sample size, and a sample size trajectory. A random shock, inversely associated with sample size, is then created for each provider. Observed outcome scores, derived as a function of true outcome quality, patient risk, and the random shock are created for each hospital. Using only information on observed outcomes, true outcomes are then estimated using the candidate outcome estimators and the performance of these estimators is compared. The performance of these estimators will then be validated for hospitals and physicians using national Medicare data and data from Massachusetts. To evaluate the effect of the MassHealth program on quality, costs, and racial and ethnic disparities, I will draw on methods employed in my previous research. This will involve the use of panel data econometric techniques to test whether Massachusetts hospitals increased quality and decreased cost for MassHealth patients after the program was implemented. To examine the effect of the program on disparities, I will test for reductions in both within-hospital disparities in quality and between-hospital disparities in quality after the program was implemented. The skills and knowledge required to pursue my proposed research will be bolstered by an outstanding group of mentors and a robust education and career development plan. My mentors are leaders in the fields of payment and financing of healthcare, quality measurement, organizational research, health economics, and comparative effectiveness. Further, my mentors employ insights and perspectives from economics, political science, sociology, and clinical practice in their research, providing a rich and diverse intellectual environment from which I can draw upon as a mentee. In following my career development plan, I will enhance my methodological and programming skills, learn more about the responsible conduct of research, acquire knowledge of clinical practice and medical organization, and present my research findings and interact with colleagues at several national conferences. Research that successfully fulfills the aims of my K01 proposal will have important policy relevance. The proposed research will add to our knowledge about the use of outcome measures in pay-for-performance and public quality reporting while also providing further evidence about the effectiveness of pay-for- performance through the evaluation of the Massachusetts program. While ambitious, my track record of research achievement shows that I am capable of conducting research that achieves these aims. Further, the coursework and applied research conducted for the K01 will augment my research skills, enhancing my ability to achieve these aims. After collaborating with my mentors on this research, I will be have established myself as a researcher in the fields of P4P and quality measurement, positioning myself for R01 grants in these areas. PUBLIC HEALTH RELEVANCE: The proposed project has the potential to positively impact public health by creating more accurate estimators of healthcare provider outcome quality and cost and by contributing to the understanding of the effect of hospital-based pay-for-performance. This research can be used to design payment policy that creates stronger incentives for value and quality improvement in healthcare.