Exploring Medicare Provider Networks: Implications for Adoption of CER Findings

描述（由申请人提供）：如果比较有效性研究（CER）是在不影响健康结果的情况下减少卫生支出增长，提供者将需要采用被确定为不低于高成本临床策略的长期成本节约策略。在考虑旨在促进使用低成本有效医疗保健的卫生改革时，了解医疗保健提供者“虚拟”网络如何影响医疗保健的成本和内容可能很重要。我们建议确定决定或影响使用节省成本但有效的临床策略的因素。我们进一步建议调查医疗保险提供者网络（虚拟或社会网络）及其结构对所提供护理的成本和内容（例如，循证实践或非循证实践）的影响。我们的具体目标是：1)确定供应和需求因素预测提供者采用节省成本的循证研究结果的程度；2)分析提供者网络结构在使用循证实践和护理成本方面的差异和影响；3)根据实施这些研究结果的政策（可能通过使用支付或诸如捆绑支付或ACOs之类的医疗改革）估计潜在的医疗保险支出节省。我们的分析将基于2005年至2010年A部分和B部分以及2006年至2010年D部分的完整医疗保险索赔文件。具体来说，我们将把这些目标应用于慢性稳定型心绞痛患者的治疗，以及在基于证据的研究结果（2007年的COURAGE试验）发表之前和之后，支持最初使用医疗管理的冠状动脉支架重建术的使用。我们将从发表前后的医疗保险索赔文件中确定相关队列，并在数据中确定预测从支架血运重建术到医疗管理的提供者实践变化的因素。我们将控制人口统计学和患者水平特征，调查生态和供应决定因素，并调查不同地域和患者亚群（如女性、少数民族和糖尿病患者）之间的差异。接下来，我们将在医疗保险数据中识别慢性稳定型心绞痛的提供者网络，并探讨提供者网络结构是否会影响所提供护理的成本或内容（与循证实践是否一致）。我们将探讨网络结构是否存在地域差异，以及这是否在一定程度上解释了地区间实践变化和成本的差异。我们将确定将我们的研究结果纳入卫生改革政策的方法，以优化我们确定为低成本但有效的护理决定因素的因素，或鼓励有效的提供者网络形成。最后，我们将根据这些政策估计潜在的医疗保险储蓄。

DESCRIPTION (provided by applicant): If comparative effectiveness research (CER) is to reduce health expenditure growth without compromising health outcomes, providers will need to adopt long-term cost-saving strategies that are identified as being no less effective than higher-cost clinical strategies. Understanding how provider "virtual" networks for Medicare influence the cost and content of care may be important when considering health reforms designed to promote the use of lower-cost effective medical care. We propose identifying factors that determine or influence the use of cost-saving yet effective clinical strategies. We further propose investigating the influence of Medicare provider networks (virtual or social networks) and their structure on the cost and content (e.g., evidence-based practices or not) of care provided. Our specific aims are to: 1) determine the extent to which supply and demand factors predict provider adoption of cost-saving evidence-based findings, 2) analyze provider network structure for differences in and influence on the use of evidence-based practices and costs of care, 3) estimate potential Medicare expenditure savings based on policies implementing these findings (perhaps through the use of payment or health reforms such as bundled payments or ACOs). We will base our analysis on the complete Medicare claims files for Parts A and B from years 2005 to 2010 and Part D from 2006 to 2010. Specifically, we will apply these aims to the treatment of patients with chronic stable angina and the use of revascularization with coronary stents before and after evidence-based findings (the COURAGE trial in 2007) were published supporting the initial use of medical management. We will identify the relevant cohort from the Medicare claims files for the time period before and after the time of publication, and identify factors that predicted a change in provider practices from revascularization with stents to medical management in the data. We will control for demographic and patient-level characteristics, investigate ecological and supply determinants, and investigate differences across geographies and patient sub-populations such as women, minorities, and those with diabetes. Next, we will identify provider networks of care for chronic stable angina in the Medicare data, and explore whether provider network structure influences the cost or content of care provided (concordant with evidence-based practices or not). We will explore whether network structures differ across geographies, and whether this partially explains the difference in practice variation and cost between regions. We will identify ways that our findings might be integrated into health reform policies either to optimize the factors we identify as determinants of low-cost yet effective care or to encourage efficient provider network formation. Finally, we will estimate potential Medicare savings based upon these policies. PUBLIC HEALTH RELEVANCE: This project identifies factors that influence provider adoption of evidence-based, cost-saving clinical practices. It investigates the influence of "virtual" provider networks on the use of evidence-based practices and costs of care in the Medicare population, and explores how these findings could be used in health reform policies to promote evidence-based, efficient patterns of care.