BBA Effects on Geographic Variation in Post-Acute Care

描述(由申请人提供)：为了应对急诊后护理(PAC)服务支付的快速增长，国会颁布了医疗保险改革，作为1997年平衡预算法(BBA)的一部分，适用于每项PAC服务。改革规定了一系列独立的案例组合调整后的预期支付系统，每个系统都有自己的实施时间表。除整体影响外，BBA对PAC使用的影响在不同的地理区域也有很大差异。例如，从1998年到2000年，在使用熟练护理设施的情况下，中风患者与1996年相比的平均变化为2.7%。在全国范围内，这一变化在-12%到24%之间变化(美国人口普查局的九个部门)。这种不同的反应引发了人们的担忧，即医院出院过程可能是由支付政策驱动的，而不是由临床需求和个人偏好驱动的。此外，不同地区PAC使用的不同变化可能会导致不好的后果，例如提前住院。在继续努力改革PAC服务和支付系统的同时，政策制定者必须了解不同的支付机制如何与PAC使用的地域差异相关联。这项拟议的研究旨在：1)分析BBA变化前后PAC使用的地理差异；2)探索PAC的使用和成本是否在PAC环境中发生变化，以及早期医院再入院是否增加；3)调查患者、医院和市场区域特征在解释BBA前后PAC使用方面的差异。我们将分析医疗保险和医疗补助服务中心从1996年到2000年5%的医疗保险索赔数据样本，以研究BBA变化对PAC使用的地理变化的初步影响。我们将重点介绍与大量使用PAC相关的六种疾病：中风、髋关节手术、髋部骨折、慢性阻塞性肺疾病、肺炎和充血性心力衰竭。选定的疾病提供了康复和医疗条件之间的对比。在BBA变化之前和之后，PAC使用的稳定性、程度和地理变化的关联性将被检验。使用率和成本的变化将表现为PAC使用变化、住院时间和早期住院再入院之间的相关性。最后，我们将估计多项Logit模型，以探索在BBA变化后患者、医院和市场区域特征对PAC使用的贡献的变化。

DESCRIPTION (Provided by Applicant): In response to the rapid growth in payments for post-acute care (PAC) services, Congress enacted Medicare reforms as part of the Balanced Budget Act of 1997 (BBA) for each PAC service. The reforms mandated a series of separate case-mix adjusted prospective payment systems, each with its own implementation timeline. In addition to the overall effects, the BBA's effects on PAC use varied substantially across geographic areas. For example, in the case of skilled nursing facility use from 1998 to 2000, the average change relative to 1996 for stroke patients was 2.7%.at the national level, but it ranged from -12% to 24% across regions (the nine United States Census Bureau divisions). This varied response raises concerns that the hospital discharge process may be driven by payment policy rather than by clinical needs and individual preferences. Furthermore, varied changes in PAC use across regions might lead to untoward consequences, such as early hospital readmission. As efforts continue to reform PAC services and payment systems, it is essential that policymakers understand how different payment mechanisms associate with geographic variation in PAC use. The proposed study seeks to: 1) analyze geographic variation in PAC use before and after the BBA changes; 2) explore whether utilization and cost have shifted among PAC settings and whether early hospital readmission has increased; and 3) investigate how the contributions of patient, hospital, and market area characteristics in explaining PAC use differ between pre- and post-BBA periods. We will analyze the Center for Medicare & Medicaid Services' 5% sample of Medicare claims data from 1996 to 2000 to study the initial effect of the BBA changes on geographic variation in PAC use. We will focus on six diseases associated with high PAC use: stroke, hip procedure, hip fracture, chronic obstructive pulmonary disease, pneumonia, and congestive heart failure. The selected diseases provide a contrast between rehabilitative and medical conditions. The stability, the degree, and the association of geographic variation in PAC use before and after the BBA changes will be examined. Shifts in utilization and costs will be presented as correlations between changes in PAC use, hospital length of stay, and early hospital readmission. Finally, we will estimate multinomial logit models to explore changes in contribution to explain PAC use by patient, hospital, and market area characteristics after the BBA changes.