Examining payment and delivery model impacts on health equity using novel quasi-experimental causal inference methods

6000万人参加了医疗保险，7500万人参加了医疗补助，使这些计划成为 在美国医疗保健系统中最具影响力。通过他们，联邦和州政府定期 试验新的支付和交付模式，在数百万受益者身上尝试政策理念。一 这项实验的关键实验室是医疗保险和医疗补助创新中心（创新中心）。 该公司最近承诺“将股权作为每一种模式的核心”。 新的支付和交付模式可能会扩大差距（例如，风险调整不足， 选择），改善它们（例如，通过灵活的报销解决健康的社会决定因素），或 两者（不同结局和亚组）。然而，现有的方法并不适合估计 这些项目对健康公平的影响。 医疗保险和医疗补助计划和政策，因为它们很少是随机的，是使用 观察因果推理方法。一种流行的这种方法是差异中差异（diff-in-diff）， 它比较了人们接触新模型的结果变化和相同时间内的变化 在没有接触过模型的对照组中。虽然对整体计划影响有用， 标准的“不同中不同”方法不适用于公平评价。未制定目标被估量 对于公平问题，它们不适应不同分组的不同回答， 治疗效果的差异。此外，这些方法没有以卫生公平框架为基础 因此，未能使用为经历不成比例的劣势的群体量身定制的因果假设。 部分由于这些方法上的缺陷，现有的证据对公平的影响，医疗保险 替代支付模式稀少且混杂。初级保健转型模式收到的更少 关注我们建议开发和应用新的方法来研究综合初级保健加 (CPC（三）影响黑人医疗保险受益人的医疗保健。全国先进的基层医疗 家庭模式于2017-18年在18个地区推出，并将持续到2021年。我们的具体目标 1）估计CPC+对黑人医疗保险受益人的医疗保健和健康公平的影响，2） 估计黑人医疗保险受益人亚组内CPC+响应的变化， 性别，残疾和双重资格的医疗补助的身份，和3）探索响应的变化， CPC+跨越两个背景维度：初级保健实践特征和当地卫生保健， 社会经济环境。本申请是对NOT-HS-21-014《特别强调通知》的回应 (SEN)AHRQ宣布对卫生服务研究感兴趣，以促进健康公平。

60 million people are enrolled in Medicare and 75 million in Medicaid, making these programs among the most influential in the US health care system. Through them, federal and state governments regularly experiment with new models of payment and delivery, trying out policy ideas on millions of beneficiaries. A key laboratory for this experimentation is the Center for Medicare and Medicaid Innovation (the Innovation Center), which has recently committed to “make equity a centerpiece of every model.” New payment and delivery models may either widen disparities (e.g., through inadequate risk adjustment and selection), ameliorate them (e.g., by addressing social determinants of health with flexible reimbursement), or both (across different outcomes and subgroups). However, existing methods are not well suited to estimate these programs' impacts on health equity. Medicare and Medicaid programs and policies, because they are rarely randomized, are evaluated using observational causal inference methods. One popular such method is difference-in-differences (diff-in-diff), which compares changes in outcomes for people exposed to a new model versus changes over the same time in a comparison group of people not exposed to the model. While useful for overall program impacts, standard diff-in-diff methods are not suited to equity evaluations. The target estimands are not formulated for equity questions, they do not accommodate varying responses across subgroups, and they do not account for variation in treatment effects. In addition, the methods are not grounded in frameworks for health equity and thus fail to use causal assumptions tailored for groups who experience disproportionate disadvantage. Partly because of these methodological shortcomings, existing evidence on equity impacts of Medicare alternative payment models is sparse and mixed. Primary care transformation models have received even less attention. We propose to develop and apply novel methods to study how Comprehensive Primary Care Plus (CPC+) affects health care for Black Medicare beneficiaries. This national advanced primary care medical home model was introduced across 18 regions in 2017-18 and will continue through 2021. Our specific aims are 1) To estimate impacts of CPC+ on health care and health equity for Black Medicare beneficiaries, 2) To estimate variation in responses to CPC+ within subgroups of Black Medicare beneficiaries with intersecting identities of gender, disability, and dual eligibility for Medicaid, and 3) To explore variation in responses to CPC+ across two contextual dimensions: primary care practice characteristics and the local health care and socioeconomic environment. This application is in response to NOT-HS-21-014 Special Emphasis Notice (SEN): AHRQ Announces Interest in Health Services Research to Advance Health Equity.