Natural Experiments to Understand Plan and Provider Behavior in an Era of Accountability

了解责任时代的计划和提供者行为的自然实验

基本信息

批准号：
10196903
负责人：
John Michael McWilliams
金额：
$ 39.28万
依托单位：
HARVARD MEDICAL SCHOOL
依托单位国家：
美国
项目类别：
财政年份：
2009
资助国家：
美国
起止时间：
2009-04-15 至 2025-03-31
项目状态：
未结题

来源：
https://reporter.nih.gov/project-details/10196903
关键词：
Accountability Acute Affect Age Area Caring Coinsurance Competitive Bidding Contracts County Data Data Sources Disabled Persons Elderly Eligibility Determination Enrollment Evaluation Evolution Fee-for-Service Plans Foundations Goals Health Health Promotion Health care facility Heterogeneity Hospitals Incentives Length of Stay Link Measurement Measures Medicaid Medicare Methodology Methods Modeling Monitor Natural experiment Nature Outcome Outcome Measure Patient Care Patient-Focused Outcomes Patients Performance Personal Satisfaction Physicians Population Positioning Attribute Privatization Process Production Prospective Payment System Provider Randomized Research Residual state Resources Risk Risk Adjustment Services Skilled Nursing Facilities Source System Variant acute care analytical method base beneficiary bundled payment care delivery care outcomes cost design experience financial incentive flexibility geographic difference health plan high reward improved improved outcome insight intrinsic motivation patient population payment physical therapist programs provider behavior response risk selection risk sharing tool wasting

项目摘要

ABSTRACT Payment to providers and plans in Medicare has far-reaching implications for the health of the elderly and disabled. The fee-for-service basis for payment has been rightly criticized for incentivizing excessive and potentially harmful provision of care and for interfering with the production of health by linking reimbursement to specific inputs. To establish greater flexibility and accountability, Medicare has increasingly transferred financial risk to entities that can manage care—first to private plans in the Medicare Advantage (MA) program and more recently to providers directly in alternative payment models (APMs) in traditional Medicare (TM). In both models, additional payment adjustments are tied to performance on quality measures. These approaches to integrating the financing and delivery of care create opportunities to improve patient care, but empirical study has been challenging. Evidence on the merits of the MA program and the relative performance of MA and APMs has been largely observational and limited in analysis of patient experiences and health outcomes. In addition, risk contracting relies heavily on risk adjustment to profile plan or provider performance and to align resources with the needs of patient populations, but the adequacy of risk adjustment has not been well described. This project will make substantial contributions by leveraging natural experiments and new data to understand plan and provider responses to payment incentives and their implications for patients and payment system design. The project includes three aims. First, we will use natural experiments to compare performance between MA and TM and different variants of each system. Sources of quasi-randomization to MA vs. TM will include differences across state and county borders in MA exposure and transitions from Medicaid to dual eligibility at age 65 in areas of high or low MA exposure. We will explore effect heterogeneity based on geographic variation in the configuration of MA (e.g., by plan type) and TM (e.g., by APM activity). Second, we will assess the marginal value of post-acute care in skilled nursing facilities (SNFs) and effects of incentives to alter post-acute length of stay on patient outcomes in different payment models, including TM, MA, and APMs. Post-acute care is an area of intense activity in MA and APMs that offers insights into provider agency. Approaches will make use of discontinuities in SNF reimbursement and coinsurance related to length of stay and natural randomization of patients to physical therapists in hospitals. Third, we will determine the extent to which risk-adjusted MA-TM differences in outcomes reflect performance differences vs. residual risk selection and assess the adequacy of risk-adjustment methods. We will use strategies from our first aim to compare MA- TM performance differences in self-sorted vs. quasi-randomized populations. Findings will characterize the prospects for value-enhancing competition or unintended consequences from prospective payment systems and will have important implications for the validity of quality scores. Thus, the project will provide foundational evidence and insights for improving health through payment systems and performance monitoring.

抽象的向提供者付款和Medicare计划对老年人的健康和禁用。付款费用的支付基础已被正确化，以激励过量和潜在的有害提供护理和通过连接报销来干扰健康的生产到特定的输入。为了建立更大的灵活性和问责制，医疗保险已经增加了对可以管理护理的实体的财务风险 - 首先是Medicare Advantage（MA）计划的私人计划最近，直接在传统医疗保险（TM）中直接使用替代支付模型（APMS）的提供商。两种模型，额外的付款调整都与质量措施的绩效相关。这些方法整合融资和提供护理的融资创造了改善患者护理的机会，但经验研究受到挑战。关于MA计划的优点和MA的相对表现的证据 APM在很大程度上是观察性的，并且在分析患者经验和健康结果方面有限。此外，风险收缩在很大程度上依赖于对个人资料计划或提供商绩效的风险调整，并保持一致有患者人群需求的资源，但风险调整的充分性还不错描述。该项目将通过利用自然实验和新数据来为了解计划和提供者对付款激励措施的回应及其对患者的影响和付款系统设计。该项目包括三个目标。首先，我们将使用自然实验比较性能在MA和TM之间以及每个系统的不同变体之间。准随机化的来源在MA暴露和从医疗补助到双重的过渡中包括各州和县边界的差异在高或低MA暴露区域的65岁时资格。我们将基于 MA配置的地理变化（例如，按计划类型）和TM（例如，通过APM活动）。第二，我们将评估熟练护士设施（SNF）急性后护理的边际价值，并激励措施对在包括TM，MA和APM在内的不同付款模型中的患者结局上更改急性后住院时间。急性后护理是MA和APM中激烈活动的领域，可提供对提供商代理的见解。方法将利用与住宿时间有关的SNF报销和共同保险中的不连续性和医院中物理治疗师的自然随机化。第三，我们将确定哪些风险调整后的MA-TM差异反映了绩效差异与剩余风险选择并评估风险调整方法的充分性。我们将使用第一个目标中的策略来比较MA- 自我分级与准随机群体的TM性能差异。调查结果将表征潜在的竞争前景或预期支付系统的意外后果并将对质量分数的有效性具有重要意义。那将提供基础通过支付系统和绩效监控来改善健康的证据和见解。