Health Systems and High-Need Populations: The Effect of Vertical Integration on Utilization, Spending, and Quality for Medically ComplexPatients

项目总结 在美国，医疗保健越来越多地在医疗系统中提供--医疗保健机构 研究和质量定义为至少有一家医院和一个医生小组的组织 提供通过共同所有或联合管理运作的全面护理。在过去 十年来，卫生系统对医生执业的获取显著增加；美国超过一半的人。 医生现在隶属于637个医疗系统之一。先前的研究发现，垂直一体化 可能导致更高的商业医疗保健价格，但对质量、支出和利用率有不确定的影响 对于联邦医疗保险受益人。关于卫生系统的扩展如何影响医疗保健，人们知之甚少 复杂的医疗保险患者，具有很高的健康需求并与 医疗系统。这项拟议研究的长期目标是确定健康的增长 系统改善了对医疗复杂患者的护理，以及卫生系统的哪些战略和特点 对他们这样做的成功或失败做出贡献。该项目的总体目标是提供医疗保健 了解卫生系统是否以及如何改变卫生系统的提供和 医疗复杂的医疗保险受益人的护理质量，重点是获得性初级保健的患者 练习。中心假设是，平均而言，卫生系统获得实践改善了护理 对于医学上复杂的患者，但这种改善在不同的医疗系统中有所不同。这些假设将是 通过追求三个具体目标进行测试：(1)确定卫生系统获得初级保健的影响 对复杂医学患者的利用、费用和质量的实践(总体和三个月 亚群)；(2)检查卫生系统在医疗支出和质量变化方面的差异 在复杂的患者后天实践，并确定系统的特点，最大限度地改善他们的护理； 以及(3)了解医生的经验和卫生系统领导人的努力在 改善对医学复杂患者的护理的系统，在获得性实践中，而不是非获得性实践。这 该项目将使用研究人员收集的医疗保险索赔数据和定性数据。在方法论上，它将 采用严格的准实验方法，包括差异分析以及在 对卫生系统领导人和执业医生进行深度、半结构化的访谈。拟议的研究 在申请者看来，这是创新的，因为它填补了关于是否健康、哪种健康以及如何健康的关键空白 系统收购改善了对医疗复杂患者的护理。它还将建立在AHRQ之前的投资基础上 开发美国卫生系统纲要，并为以下方面提供一个扩展的数据库 其他研究人员可以使用。该项目意义重大，因为它将提供关于 跨一系列质量、利用率和支出成果的垂直集成，并将确定以下战略 可以改进医疗体系的设计，创造更高价值的医疗体系。

PROJECT SUMMARY Medical care in the United States is increasingly delivered in health systems—which the Agency for Healthcare Research and Quality has defined as organizations with at least one hospital and one physician group providing comprehensive care that operate through common ownership or joint management. In the past decade, health system acquisition of physician practices has increased markedly; more than half of U.S. physicians are now affiliated with one of 637 health systems. Prior research has found that vertical integration can lead to higher commercial health care prices, but has uncertain effects on quality, spending, and utilization for Medicare beneficiaries. Little is known about how health system expansion influences care for medically complex Medicare patients, a distinct population that has high health needs and frequent interactions with the medical system. The long-term goal of the proposed research is to determine whether the growth of health systems improves care for medically complex patients and what health system strategies and characteristics contribute to their success or failure in doing so. The overall objective of this project is to provide health care leaders and policymakers with an understanding of whether and how health systems change the delivery and quality of care for medically complex Medicare beneficiaries, with a focus on patients in acquired primary care practices. The central hypotheses are that, on average, health system acquisition of practices improves care for medically complex patients, but that improvement varies across health systems. These hypotheses will be tested by pursuing three specific aims: (1) determine the impact of health system acquisition of primary care practices on utilization, spending, and quality for medically complex patients (overall and for three subpopulations); (2) examine variation by health system in spending and quality changes for medically complex patients at acquired practices, and identify characteristics of systems that most improve their care; and (3) understand how the experiences of physicians and the efforts of health system leaders differ at systems that improve care for medically complex patients at acquired practices from those that do not. This project will use Medicare claims data and qualitative data collected by the researchers. Methodologically, it will employ rigorous quasi-experimental approaches including difference-in-differences analyses, as well as in- depth, semi-structured interviews with health system leaders and practicing physicians. The proposed research is innovative, in the applicants' opinion, because it fills critical gaps about whether, which, and how health system acquisitions improve care for medically complex patients. It will also build on AHRQ's prior investment in developing a Compendium of U.S. Health Systems, and make an expanded database publicly available for other researchers to use. The project is significant because it will provide rigorous evidence on the impact of vertical integration across a range of quality, utilization, and spending outcomes and will identify strategies that may improve the design of health systems to create a higher value medical system.