Unintended Consequences: Medicare Performance Programs and Health Disparities

 描述（由申请人提供）：近年来，通过公开报告医院绩效、推广医疗之家和发展全球支付机制，医疗保健领域发生了转型变化，所有这些都旨在提高护理质量和价值。为了加速和巩固这一进程，2010年的《患者保护和平价医疗法案》（ACA）规定了两个基于绩效的财务激励计划，覆盖了全国大部分医院：医院再入院减少计划（HRRP）和基于价值的采购（VBP）计划。从2012年开始，这些计划根据医院在一系列指标上的表现（再入院、护理过程、患者护理体验、死亡率），激励医疗保险报销率的增加（“奖励”）或减少（“惩罚”），其中一些涵盖所有患者，另一些涵盖急性心肌梗死、心力衰竭和肺炎的急性入院患者。 尽管这些方案旨在鼓励评估和改善护理质量，但它们引起了人们对医院潜在不利影响的极大关注，因为这些医院照顾的是比例过高的少数民族和族裔（“少数民族服务医院”）或无保险和保险不足的病人（“安全网医院”）。首先，有证据表明，病人的结果，如再入院，是由医院流程的影响以外的因素，包括获得门诊治疗，家庭和社会支持的影响;因此，HRRP和VBP，使用医院基准，使没有考虑到患者的社会人口或临床严重程度的差异，可能会导致更高的风险处罚少数民族服务和安全网医院。其次，由于少数民族服务和安全网医院提供更多的无偿护理，导致对公共补贴的依赖程度更高，他们对护理质量改善的投资可能会更小;为了加剧这一挑战，医疗保险计划的财务处罚可能会对资源贫乏的医院的患者护理和结果产生更大的不利影响，因为它们的营业利润率低。 为了评估这些问题，拟议的研究旨在检查这些方案的实施经验的数据。使用医疗保险患者和医院层面的数据（2008-2015年），以及基于暴露于计划的医院与未暴露于计划的医院的比较的差异中差异研究设计，我们的目的是估计计划对（a）医院绩效和（B）患者结局的影响- 30天死亡率和再入院-按种族/民族和社会经济地位。此外，我们将探索绩效计划的替代修改，以激励安全网和少数民族服务医院提高护理质量。

 DESCRIPTION (provided by applicant): In recent years, the healthcare landscape has undergone transformational changes, through public reporting of hospital performance, promotion of medical homes, and development of global payment mechanisms, all directed at improved quality and value of care. To accelerate and solidify this process, the Patient Protection and Affordable Care Act (ACA) of 2010 mandated two programs of performance-based financial incentives covering a majority of hospitals nationwide: the Hospital Readmissions Reduction Program (HRRP) and the Value-Based Purchasing (VBP) program. Beginning in 2012, the programs incentivized an increase ("reward") or decrease ("penalty") in Medicare reimbursement rates based on hospital performance on a range of measures - readmissions, process of care, patient experience of care, mortality - some covering all patients and others covering patients with acute admissions for acute myocardial infarction, heart failure, and pneumonia. Although intended to encourage evaluation and improvement of quality-of-care processes, these programs have raised considerable concern for potential adverse impact in hospitals that care for disproportionately large share of racial and ethnic minorities ("minority-serving hospitals") or uninsured and underinsured patients ("safety-net hospitals"). First, evidence indicates that patient outcomes, such as readmissions, are affected by factors beyond the influence of hospital processes, including access to outpatient care, and family and social supports; consequently, HRRP and VBP, using hospital benchmarks that make no allowance for differences in patient socio-demographic or clinical severity profiles, may lead to higher risk of penalties for minority-serving and safety-net hospitals. Second, as minority-serving and safety-net hospitals provide more uncompensated care, leading to greater reliance on public subsidies, their investments for quality-of-care improvements are likely to be smaller; to compound this challenge, financial penalties from the Medicare programs may have a greater adverse impact for patient care and outcomes in the resource-poor hospitals due to their low operating margins. To evaluate these concerns, the proposed study aims to examine data from the implementation experience of these programs. Using Medicare patient-level and hospital-level data (2008-2015), and a difference-in-differences study design based on comparison of hospitals exposed to the programs with those not exposed, we aim to estimate program effects on (a) hospital performance, and (b) patient outcomes - 30- day mortality and readmission - by race/ethnicity and socioeconomic status. In addition, we will explore alternative modifications in performance programs to incentivize safety-net and minority-serving hospitals to improve quality of care.