Joint Effect of Malpractice Risk and Financial Incentives on Cardiac Testing

描述（由申请人提供）：心脏检测是医疗保健成本和成本增长的主要贡献者。有大量证据表明，心脏测试被过度使用。过度使用的两个潜在原因是测试提供者的盈利能力和他们对医疗事故责任的恐惧。我们研究的一个中心目标是研究责任风险和经济激励如何单独和共同影响心脏检查率和患者结局。没有事先 一项研究调查了这两个因素对心脏检查率的影响;在任何医疗保健领域，以前都没有研究过责任风险和经济激励之间的相互作用。这些互动可能很重要。如果测试是有利可图的，医疗事故风险和盈利能力都可能导致测试过度使用。相反，如果检测无利可图，医疗事故风险可以为检测率提供一个“底线”，从而限制未充分使用。我们将研究这些问题，依赖于外部冲击的医疗事故风险和报销作为可信的因果关系推断的基础。对于医疗事故，我们将依靠过去十年的州改革，在此期间，九个州采用了新的损害上限。在报销方面，我们将依靠医疗保险和医疗补助服务中心（CMS）从2010年开始大幅削减门诊压力测试的报销。这些削减的风险很大。如果这些削减能遏制过度使用，CMS每年将节省数十亿美元，并可能在其他地方采取类似的削减措施。然而，如果检测从门诊转移到住院，或者提供者替代不面临削减的更昂贵的检测，支出可能会增加。此外，如果检测率低于最佳水平，削减可能会伤害患者。为了评估医疗事故风险的影响，我们将研究采用侵权法改革的州，并将其他州作为对照组。对于报销削减，我们将研究医疗保险收费服务中的心脏测试，使用医疗保险优势患者作为对照组。该项目的目标是：（1）评估医疗事故改革单独对检测率的影响;（2）评估报销削减单独对检测率和地点的影响;（3）检查医疗事故风险和报销削减之间的相互作用;（4）评估医疗事故风险和报销水平如何单独和共同影响患者结果。了解这些改革的综合影响对于确保近2000万患有冠状动脉疾病的美国人的优质护理至关重要 疾病（CAD）和每年更多的人进行测试。此外，医疗事故和支付改革的大规模实验正在进行中，而不仅仅限于心脏护理。我们的研究可以为几个领域的政策决定提供信息，包括：（i）医疗事故责任是否可以限制治疗不足的风险，这种风险以前玷污了“管理式医疗”，并可能破坏“责任式医疗”的成功？(ii)报销削减，如门诊压力测试限制测试过度使用，或他们会有意想不到的后果-无论是提高成本或降低医疗质量？以及（iii）医疗事故风险的最佳水平如何随医疗服务提供者报销的性质而变化？

DESCRIPTION (provided by applicant): Cardiac testing is a major contributor to health care costs and cost growth. There is substantial evidence that cardiac testing is overused. Two potential reasons for overuse are test profitability to providers and their fear of medical malpractice liability. A central goal of our study is to examine how liability risk and financial incentives, individually and jointly influence cardiac testing rates and patient outcomes. No prior study examines the impact of either factor on cardiac testing rates; no prior study in any area of medical care studies the interactions between liability risk and financial incentives. These interactions are likely to be important. If testing is profitable, both malpractice risk and profitability could induce test overuse. In contrast, if testing is unprofitable, malpractice risk could provide a "floor" on testing rates, and thus limit underuse. We will study these issues, relying on external shocks to malpractice risk and reimbursements as a basis for credible causal inference. For malpractice, we will rely on state reforms over the last decade, during which nine states adopted new damage caps. For reimbursements, we will rely on large cuts by the Centers for Medicare and Medicaid Services (CMS), beginning in 2010, to reimbursement for outpatient stress testing. The stakes for these cuts are large. If these cuts curb overuse, CMS would achieve billions of dollars of annual savings and might adopt similar cuts elsewhere. However, spending could rise if testing moves from outpatient to inpatient settings, or providers substitute more expensive tests which did not face cuts. Additionally, the cuts could harm patients if testing rates fall below the optimal level. To assess the impact of malpractice risk, w will study states that adopted tort reforms, using other states as a control group. For reimbursement cuts, we will study cardiac testing within Medicare fee-for-service, using Medicare Advantage patients as the control group. The project aims are to: (1) assess the impact of malpractice reforms alone on testing rates; (2) assess the impact of reimbursement cuts alone on testing rates and locations; (3) examine the interaction between malpractice risk and reimbursement cuts; and (4) assess how malpractice risk and reimbursement levels individually and jointly affect patient outcomes. Understanding the combined impact of these reforms is critical to ensure quality care for the nearly 20 million Americans with coronary artery disease (CAD) and the many more who are tested for it each year. Moreover, large scale experiments in both medical malpractice and payment reform are underway, not limited to cardiac care. Our research can inform policy decisions in several areas, including: (i) can malpractice liability limit the risks of undertreatment that previously tainted "managed care" and might undermine the success of "accountable care"?; (ii) can reimbursement cuts, such as those made to outpatient stress testing limit test overuse, or will they have unintended consequences - either raising cost or degrading care quality?; and (iii) how does the optimal level of malpractice risk vary with the nature of provider reimbursement?