CHANGING LONG-TERM CARE IN AMERICA: POLICIES, MARKETS, STRATEGIES AND OUTCOMES

描述（由申请人提供）：未来十年的一个关键政策问题是如何最好地构建激励机制和法规，以确保年老体弱的住院患者获得成本效益和协调的护理。联邦和州的政策都改变了长期护理，出现了由疗养院（NH）和其他提供者提供的急性后护理。急性后护理现在占所有医疗保险支出的约20%。我们的第一个计划项目赠款集中在国家的医疗补助政策的影响，国家卫生服务的战略选择，以及这些选择如何影响病人的结果。我们发现，不仅国家的政策影响供应商的投资，可以积极或消极地影响居民的结果，我们还发现，医疗保险政策影响医疗补助提供者和国家的医疗补助政策影响医疗保险的病人，往往在一个功能失调的方式。事实上，针对急性医院的医疗保险政策变化“涓滴”影响大多数国家卫生机构，进一步突出了长期和急性后护理政策领域的相互联系。因此，医疗补助和医疗保险政策是交织在一起的;当医疗保险政策改变时，即使只针对医院，NH和其他PAC提供者也会受到影响。由于《平价医疗法案》（ACA）代表了几十年来医疗保险和医疗补助的最大政策变化，我们认为必须了解其对急性护理和急性后护理界面的影响。我们提出的三个项目和核心都集中在急性期后护理（PAC）日益增长的作用上;每个项目都有历史目标以及检查平价医疗法案（ACA）影响的目标。项目#1询问与NH合作伙伴关系密切的医院是否具有较低的再住院率。项目#2检查医院的方法来配备主治医生的角色对虚弱，住院NH居民的经验的影响。最后，项目#3首次研究了PAC在医疗保险管理医疗中的使用，以及患者如何应对PAC的自付结构变化。

DESCRIPTION (provided by applicant): A key policy question for the coming decade is how best to structure incentives and regulations to insure that frail older hospitalized patients receie cost effective and coordinated care. Both federal and state policy has transformed long-term care with the emergence of post-acute care provided by nursing homes (NH) and other providers. Post-acute care now represents approximately 20% of all Medicare spending. Our first Program Project grant focused on the effect of states' Medicaid policies on the strategic choices that NHs make and how those choices impact patient outcomes. We find that not only do states' policies influence providers' investments which can positively or adversely affect residents' outcome, we've also found that Medicare policies affected Medicaid providers and states' Medicaid policies affected Medicare patients, often in a dysfunctional manner. Indeed, Medicare policy changes directed at acute hospitals "trickle down" to impact most NHs further highlighting the interconnectedness of long term and post-acute care policy domains. Thus, Medicaid and Medicare policies are intertwined; when Medicare policies change, even if only directed at hospitals, NHs and other PAC providers are affected. Since the Affordable Care Act (ACA) represents the biggest policy change to Medicare and Medicaid in decades, we believe it is imperative to understand its effects on the acute care and post-acute care interface. The three projects and cores we propose all focus on the growing role of post-acute care (PAC); each has historical aims as well as aims that examine the impact of the Affordable Care Act (ACA). Project #1 asks whether hospitals with strong relationships with NH partners have lower re-hospitalization rates. Project #2 examines the impact of hospitals' approaches to staffing the attending physician role on frail, hospitalized NH residents experience. Finally, Project #3 examines, for the first time, the use of PAC by Medicare managed care and how patients respond to changing co-pay structures for PAC.