Improving Medicare in an Era of Change: Impact of Private Equity Acquisitions of Hospitals and Physicians on the Care of Medicare Beneficiaries with ADRD

项目摘要/摘要 成功地将筹资和提供医疗服务结合起来仍然是医疗保险计划的主要目标 经过多年的扩大努力，包括最近一段时间史无前例的试验。由此产生的 医疗保险的变化创造了了解支付系统如何影响患者护理和 结果。联邦医疗保险优势(MA)计划是联邦医疗保险在整合资金方面最重要的尝试 和关心。目前，36%的受益人参加了可以影响患者护理的首肯私人计划 通过多种机制取得成果，包括选择性签约、福利设计和护理 管理层。鉴于大多数受益人仍在传统联邦医疗保险(TM)，联邦医疗保险已经 实施了将筹资和护理纳入该方案的努力，包括替代付款 医疗保险直接与供应商签订风险合同的模式(APM)。MA优点的证据是 主要是观察性的，对APM的相对性能知之甚少。此外，这一现象的影响 对患者的综合融资和交付仍然不清楚，研究不足。直到最近，关于MA的数据 计划不足以支持对护理模式差异的详细实证探索 驱动它们的潜在机制。从州医疗补助计划中可以学到很多潜在的经验教训，这些计划通常 使用比MA计划更窄的提供者网络，并且越来越多地将护理管理委托给私人 计划，但在医疗补助和医疗保险中采取的方法对患者护理的相对影响尚未 量化的。在各种整合倡议中都认识到，一刀切并不适用于所有人；付款 具有前瞻性或包含前瞻性元素，为计划和提供商提供了更大的灵活性 选择护理投入，以支持患者的健康和福祉。但对于患有特殊疾病的患者来说 人们对需求知之甚少。在支付系统设计和绩效监测方面仍然存在许多挑战， 特别是在风险调整的方法上。因此，随着医疗保险的创新和发展，需要进行合理的分析 为了解支付系统如何影响患者而生成证据基础。本计划项目， “在变革的时代改进医疗保险”，重点关注改变医疗保险计划的后果 病人护理和结果。旨在为设计医疗支付系统提供基础性的见解 关心。我们的研究议程包括四个关键领域：1)MA和TM的比较性能以及 每个方案的变体；2)MA计划采用的策略；3)向州医疗补助计划学习；以及4) 医保痴呆症患者的经验及其对完善医保支付制度的启示 有特殊需要的病人。我们的建议书通过利用新数据建立在当前计划项目的基础上 来源和经验方法：审查以前无法回答的问题；支持严格的制度 比较；并通过探索支付和交付的差异来确定潜在的改进方向 在日益多样化的医疗保险和医疗补助计划中的系统功能。

PROJECT SUMMARY/ABSTRACT Successfully integrating the financing and delivery of care remains a primary goal of the Medicare program after years of expanding efforts, including a recent period of unprecedented experimentation. The resulting changes in Medicare have created opportunities to understand how payment systems affect patient care and outcomes. The Medicare Advantage (MA) program is Medicare's most significant attempt to integrate financing and care. Currently 36% of beneficiaries are enrolled in capitated private plans that can influence patient care and outcomes through multiple mechanisms, including selective contracting, benefit design, and care management. Given that the majority of beneficiaries remain in Traditional Medicare (TM), Medicare has implemented efforts to integrate financing and care in that program as well, including alternative payment models (APMs) in which Medicare risk-contracts with providers directly. The evidence on the merits of MA is largely observational, and little is known about the relative performance of APMs. Moreover, the implications of integrated financing and delivery for patients remain unclear and understudied. Until recently, data on the MA program were insufficient to support detailed empirical exploration of differences in care patterns and the potential mechanisms driving them. Potential lessons abound from state Medicaid programs, which typically use narrower provider networks than MA plans and have increasingly delegated care management to private plans, but the relative impact on patient care of approaches taken in Medicaid and Medicare have not been quantified. There is recognition across the various integration initiatives that one size does not fit all; payments that are prospective, or incorporate prospective elements, give plans and providers greater flexibility in selecting inputs of care to support patients' health and well-being. But the implications for patients with special needs are poorly understood. Many challenges remain in payment system design and performance monitoring, particularly in methods of risk adjustment. Thus, as Medicare innovates and evolves, sound analysis is needed to generate an evidence base for understanding how payment systems affect patients. This Program Project, “Improving Medicare in an Era of Change,” focuses on the consequences of a changing Medicare program for patient care and outcomes. It intends to supply foundational insights for designing payment systems in health care. Our research agenda encompasses four key areas: 1) comparative performance of MA and TM and variants of each; 2) strategies employed by MA plans; 3) learning from state Medicaid programs; and 4) experiences of Medicare patients with dementia and their implications for payment system refinements for patients with special needs. Our proposal builds on our current Program Project by leveraging new data sources and empirical approaches to: examine previously unanswerable questions; support rigorous system comparisons; and identify potential directions for improvement by exploring variation in payment and delivery system features in the increasingly heterogeneous Medicare and Medicaid programs.