Identifying Cascades of Low-Value Care and the Organizational Practices that Prevent Them

项目摘要 减少使用低价值护理--潜在危害超过可能益处的护理--是 有吸引力但难以实现的目标。这是为数不多的机会，提高质量，同时减少 在护理方面的支出，但传统上很少有共识，什么是低价值的护理， 有机会衡量它并设计针对它的干预措施。近年来， 美国和其他国家的医生领导的努力，以建立共识，围绕什么测试和 一些初步分析旨在量化低价值的使用， 特别是在医疗保险受益人中。许多被确定为低价值的服务是常规成像， 实验室测试这些服务的成本和风险相对较低，但它们可能会引发一系列 后续服务，或低价值护理的整个患者事件，对患者 结果和医疗保健支出。很少有人知道（一）低- 价值关怀，包括指数测试产生的后续相关服务的成本;（二） 对使用低价值护理和相关事件的支付改革干预;以及（iii）哪些特征 提供者组织的最佳定位，以减少低价值护理的使用。弥补这些知识差距， 减少低价值护理既可以减少对患者的伤害，也可以减少不必要的支出。 本研究的目的1是构建低价值测试集，包括测试、程序和治疗 与初始低值测试相关，并检查每集的患病率和成本。该分析将建立 基于先前开发的基于索赔的过度使用措施，并依赖于使用100%的收费服务 医疗保险数据。目标2将侧重于责任护理组织（ACO）的实施对 利用低价值护理的机会。《平价医疗法案》授权医疗保险中心和 医疗补助服务与ACO签订合同，ACO是负责定义的医疗保健的提供者网络 人口如果ACO提供者能够减缓患者医疗保健的增长， 同时保持或提高他们提供的护理质量。目标2将涉及分配医疗保险 使用索赔数据并检查低价值护理事件的利用率和成本， 与当地对照组相比，在Medicare ACO中实施ACO后。数据来自四 然后，全国ACO调查的浪潮将与医疗保险索赔联系起来，以了解Aim 3， ACO的特点是最密切相关的成功减少利用低价值的护理。我们 还将采访10名高绩效的ACO，以确定减少低绩效的策略、促进者和挑战， 价值服务。这项研究将为未来测量低价值护理事件提供工具， ACO政策的演变，因为它涉及到模型的能力，以减少利用低价值的护理。

PROJECT SUMMARY Reducing use of low-value care – care for which potential for harm exceeds the possible benefit – is an attractive but elusive goal in health care. It is one of the few opportunities to increase quality while decreasing spending on care, but there was traditionally little consensus on what constitutes low-value care and little opportunity to measure it and design interventions to target it. That has changed in recent years as a result of physician-led efforts in the United States and other countries to build consensus around what tests and procedures qualify as low-value, and a number of preliminary analyses aimed at quantifying use of low-value care, particularly among Medicare beneficiaries. Many services identified as low-value are routine imaging and laboratory tests. These services can be relatively low-cost and low-risk but they may initiate a cascade of subsequent services, or an entire patient episode of low-value care, with much greater impact on both patient outcomes and health care spending. Little is know about (i) the prevalence and variation in episodes of low- value care, including the cost of subsequent related services stemming from the index test; (ii) the effect of payment reform interventions on use of low-value care and related episodes; and (iii) which characteristics best position a provider organization to reduce use of low-value care. Addressing these knowledge gaps and reducing low-value care will both decrease harm to patients and reduce unnecessary spending. Aim 1 of this study is to construct episodes of low-value testing that include tests, procedures, and treatments related to an initial low-value test, and examine the prevalence and cost per episode. This analysis will build upon previously developed claims-based measures of overuse, and rely on use of 100% fee-for-service Medicare data. Aim 2 will focus on the effect of accountable care organization (ACO) implementation on utilization of episodes of low-value care. The Affordable Care Act authorized the Centers for Medicare and Medicaid Services to contract with ACOs, networks of providers responsible for the health care of a defined population. ACO providers are rewarded financially if they can slow growth in their patients’ health care spending while maintaining or improving the quality of care they deliver. Aim 2 will involve assigning Medicare beneficiaries to ACOs using claims data and examining utilization and costs of episodes of low-value care pre- and post-ACO implementation in Medicare ACOs as compared with local control groups. Data from four waves of The National Survey of ACOs will then be linked with Medicare claims to understand, in Aim 3, which ACO characteristics are most closely associated with successful reduction in utilization of low-value care. We will also interview ten high-performing ACOs to identify tactics, facilitators, and challenges to reducing low- value services. This study will provide tools for future measurement of episodes of low-value care and inform the evolution of ACO policy as it pertains to the model’s capacity to reduce utilization of low-value care.