Learning from Medicare Payment Reform: Economic Effects of ACO Incentives

描述（由申请人提供）：政策制定者已经接受了按绩效付费和共享储蓄/风险模式，以改善公共资助的医疗保健计划的医疗保健和适度的成本增长。公共和私人支付者都坚定地承诺从基于数量的支付转向奖励价值的支付模式。《平价医疗法案》授权医疗保险与负责任的医疗组织（ACOs）签订合同，ACOs是负责特定人群医疗保健的提供者网络。虽然这些项目的实施进展迅速，但几乎没有证据表明这些项目是否有潜力在提高质量的同时节省真正的成本。在此申请的R21阶段，我们将完成对医疗保险医师团体实践示范的评估，这是10个多专业医师团体的绩效联合支付和共享储蓄努力。医师团体执业示范改革在许多方面与目前立法的ACO改革相似，因此有资格成为迄今为止我们所拥有的ACO激励效果的最佳证据。然而，除了奖金支付和10家网站公开报告的质量分数之外，人们对激励计划的总体影响知之甚少

DESCRIPTION (provided by applicant): Policymakers have embraced pay-for-performance and shared savings/risk models to improve healthcare and moderate cost growth in publically funded healthcare programs. There is a strong commitment by both public and private payers to move from volume-based payment toward payment models rewarding value. The Affordable Care Act authorized Medicare to contract with accountable care organizations (ACOs), networks of providers responsible for the health care of a defined population. While implementation of these programs is moving forward rapidly, there is little evidence to guide whether these programs have the potential to yield real cost savings while improving quality. Under the R21 phase of this application, we will complete an evaluation of Medicare's Physician Group Practice Demonstration, a joint pay-for-performance and shared savings effort in 10 multi-specialty physician groups. The Physician Group Practice Demonstration reforms are similar in many respects to the currently legislated ACO reforms, and thus qualify as the best evidence we have to date of the effects of ACO incentives. Yet beyond bonus payments and quality scores publicly reported for each of the ten sites, little is known about how the incentive scheme affected overall costs, quality or outcomes. Our data analysis begins with a simple difference-in-difference strategy, with local Medicare beneficiaries as controls, to measure the effect of the Demonstration on Medicare payments and quality metrics beyond those measured for payment purposes. We will expand the comparison groups to similar physician practices beyond local controls and will focus on accounting for selection into the program and the role of risk adjustment in study of costs and outcomes. In addition, a major objective of our research will be to develop a structural model of Medicare payment reform incentive schemes, with parameters estimated using outcomes arising from the Physician Group Practice Demonstration, that we believe can explain some part of the heterogeneity observed in provider responses to the PGPD. The milestones for completion of the R21 phase will include development of a theoretical model of ACO incentive schemes, completion of appropriate control groups and estimation of a selection model, specification of appropriate quality and outcome measures, and adequate risk adjustment measures. In the R33 phase of the application, we will apply techniques and models developed in the R21 phase to the Pioneer and Medicare Shared Savings Programs, which will include a greater number of accountable care organization participants and more subtleties in incentive design.