Examining the effects of Global Budget Revenue Program on the Costs and Quality of Care Provided to Cancer Patients Undergoing Chemotherapy

项目摘要/摘要 2014年，根据一项联邦豁免，马里兰州颁布了一项全额支付全球预算收入(GBR) 这种模式前瞻性地对医院收入设定了限制。它还要求国家限制人均 支出和强制减少可预防的并发症和重新入院。GBR的实施是 与医疗保险信托基金的节省相关，目前正在考虑扩大 计划到其他地区。然而，人们对GBR对癌症传递的影响的了解有限- 相关服务。虽然GBR可能会激励减少医疗支出和护理 平均而言，它的改善可能与意想不到的效果和癌症治疗效果不佳有关 通过限制获得有效的癌症治疗来减少对患者的伤害。GBR可能会对流行的 通过鼓励对少数族裔和患有癌症的患者进行不利的患者选择来实现癌症护理的不公平 由于对更高的支出和更糟糕的临床结果的担忧，社会经济脆弱性。当前 对GBR计划的评估没有审查这些影响。我们的目标是解决这一证据差距 这项提议。我们的研究很重要，因为急性医院护理，GBR激励的重点，是一个关键 癌症患者总支出和地区差异的驱动力。 这项建议的目标是通过差异性设计系统地检查影响 关于按服务收费的医疗保险受益人的支出、医疗质量和利用率的GBR模式 与马里兰州患有癌症的非老年医疗补助和商业保险受益人相比 处于对照状态的相似患者。我们的中心假设是，GBR的财务激励将降低 支出，提高护理质量，并促进化疗管理护理地点的转移 我们感兴趣的人群。此外，我们假设GBR的实施将导致相对较差的情况 临床结果和对历史上被边缘化的患者的相对更大的支出。我们将测试我们的 假设并实现我们的目标，具体目标如下：目标1：量化GBR对 接受化疗的受益人的风险调整支出。目标2：评估GBR对 接受化疗的可能性和接受化疗的受益人的护理质量。目标 3：评估GBR对化疗类型(医生给药与口服)和部位的影响 医生管理的化疗(医院门诊部与医生办公室设置)。目标4： 评估实施GBR对历史上边缘化患者的护理提供的不同影响， 基于地区一级的剥夺、种族和族裔以及双重资格地位，这些人正在经历 化疗。我们的发现将有意义地促进我们对如何提供高效、高效的 为成年患者提供优质的癌症护理。它还将向政策制定者提供及时的信息，以指导 更新GBR，并减轻未来全球预算举措中出现意外后果的风险。

Project Summary/Abstract In 2014, the state of Maryland, under a federal waiver, enacted an all-payer Global Budget Revenue (GBR) model that prospectively set limits on hospital revenue. It also required the state to limit growth in per-capita spending and mandated reductions in preventable complications and readmissions. GBR implementation was associated with savings to the Medicare Trust Fund and considerations are now underway to expand the program to other regions. However, there is limited understanding of GBR’s impact on the delivery of cancer- related services. It is possible that while GBR may incentivize reduced healthcare expenditures and care improvements on average, it could be associated with unintended effects and poor performance for cancer patients by limiting access to effective cancer treatments. GBR may have deleterious effects on prevailing cancer care inequities by encouraging adverse patient selection towards racial minorities and patients with socioeconomic vulnerability due to concerns about higher spending and worse clinical outcomes. Current evaluations of the GBR program have not examined these impacts. We aim to address this evidence gap in this proposal. Our research is important because acute hospital care, the focus of GBR incentives, is a key driver of overall spending and regional variation in spending for patients with cancer. The objective of this proposal is to systematically examine, via a difference-in-differences design, the impact of the GBR model on spending, quality-of-care, and utilization among fee-for-service Medicare beneficiaries and nonelderly Medicaid and commercial insurance beneficiaries with cancer in Maryland compared with similar patients in control states. Our central hypothesis is that the financial incentives in GBR will lower spending, improve care quality, and facilitate a shift in the site of care for chemotherapy administration across our populations of interest. Additionally, we hypothesize that GBR implementation will lead to relatively worse clinical outcomes and relatively greater spending for historically marginalized patients. We will test our hypotheses and achieve our objectives with the following specific aims: Aim 1: Quantify the impact of GBR on risk-adjusted spending for beneficiaries undergoing chemotherapy. Aim 2: Assess the impact of GBR on the likelihood of chemotherapy receipt and on care quality for beneficiaries undergoing chemotherapy. Aim 3: Assess the impact of GBR on the type of chemotherapy (physician-administered vs. oral) and site of physician-administered chemotherapy (hospital outpatient department vs. physician office setting). Aim 4: Assess the differential effects of GBR implementation on care delivery for historically marginalized patients, based on area-level deprivation, race and ethnicity, and dual-eligible status, who are undergoing chemotherapy. Our findings will meaningfully advance our understanding of how to deliver efficient, high- quality cancer care to adult patients. It will also provide timely information to policy-makers that would guide updates to GBR and mitigate the risk of unintended consequences in future global budget initiatives.