The impact of population and episode-based payment models on surgical disparities

项目摘要 作为全国范围内向基于价值的支付转变的突出领导者，医疗保险已经实施了大规模的 按服务付费的基于人口和时段的替代支付模式（APM）， 对医疗质量和成本负责。然而，这些杀伤人员地雷的设计目的不是为了保护 少数种族/族裔和社会经济地位低的个人的机会或结果。这些 与其他人相比，弱势群体已经面临着巨大的外科差异。这些差距 如果参与的提供者参与患者选择， 易受伤害的病人接受外科手术或在参加后改变护理。因为 政策制定者必须就如何使用不同的APM来催化全国性的改革做出关键决定， 了解基于人群和事件的APM如何影响弱势患者的手术差异， 帮助决策者确定如何最好地设计、完善和实施政策调整，并扩大不同的 保护弱势患者的护理模式。这项研究探讨了如何突出医疗收费- 与外科护理高度相关的基于服务人群和事件的APM影响以下方面的差异： 弱势患者的手术入路和结局，跨保险范围类型，以及是否影响 因供应商与APM激励措施相关的财务属性而异。我们假设APM的参与将是 与手术入路和结局（质量、利用率和成本）的差异扩大相关， 在医疗服务提供者开始参与APM后，弱势患者与非弱势患者的差异。我们还假设， 对手术差异的影响将因提供者的财务属性而异-财务风险的经验， 付款人组合-与APM激励措施相关。

Project Summary As a prominent leader in the nationwide shift towards value-based payment, Medicare has implemented large fee-for-service population- and episode-based alternative payment models (APMs) that hold organizations financially accountable for the quality and costs of care. However, these APMs are not designed to protect access or outcomes for racial/ethnic minorities and individuals with low socioeconomic status. These vulnerable groups already face significant surgical disparities compared to other individuals. These disparities could worsen further under both APM types if participating providers engage in patient selection that reduces vulnerable patients’ access to surgical procedures or changes their care after participating. Because policymakers must make critical decisions about how to use different APMs to catalyze nationwide reform, insight about how population- and episode-based APMs affect surgical disparities for vulnerable patients can help policymakers determine how to best design, refine, implement policy adjustments, and scale up different models to safeguard the care of vulnerable patients. This study examines how prominent Medicare fee-for- service population- and episode-based APMs that are highly relevant to surgical care affect disparities in surgical access and outcomes for vulnerable patients, across insurance coverage type, and whether effects vary by providers’ financial attributes related to APM incentives. We hypothesize that APM participation will be associated with widened disparities in surgical access and outcomes (quality, utilization, and cost) for vulnerable vs. non-vulnerable patients after providers begin participating in APMs. We also hypothesize that the impact on surgical disparities will vary by providers’ financial attributes – experience with financial risk and payer mix – related to APM incentives.