Medicaid Expansion and Quality, Utilization and Coordination of Health Care for Veterans with Chronic Kidney Disease

慢性肾病退伍军人医疗补助的扩展以及医疗保健的质量、利用和协调

• 批准号: 10335803
• 负责人: LAURA A PETERSEN
• 金额: --
• 依托单位: MICHAEL E DEBAKEY VA MEDICAL CENTER
• 依托单位国家: 美国
• 财政年份: 2021
• 资助国家: 美国
• 起止时间: 2021-04-01 至 2025-03-31
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10335803
• 关键词: 3-Dimensional; Accident and Emergency department; Accountability; Adopted; Affect; Affordable Care Act; American; Cardiovascular Diseases; Caring; Characteristics; Chronic; Chronic Kidney Failure; Complex; Comprehensive Health Care; Data; Diabetes Mellitus; Dialysis procedure; Dual Enrollment; Eligibility Determination; Emergency department visit; Emotional; Enrollment; Ensure; Face; Feeling; Financial Contribution; Health; Health Care Costs; Health Services Accessibility; Health system; Healthcare; Healthcare Systems; Hospitalization; Household; Improve Access; Income; Insurance Carriers; Interview; Investigation; Kidney; Kidney Diseases; Low income; Mediating; Medicaid; Medicaid eligibility; Medicare; Methodology; Mission; Modeling; Natural experiment; Outcome; Outpatients; Patient Care; Patients; Pattern; Persons; Primary Care Physician; Process; Provider; Quality of Care; Research; Resources; Risk; Services; Severity of illness; Source; Strategic Planning; Structure; Subgroup; System; Time; Transplantation; Uninsured; Uninsured Medical Expense; United States Dept. of Health and Human Services; Veterans; Visit; Work; beneficiary; care coordination; care costs; care fragmentation; care outcomes; care systems; comorbidity; cost; demographics; enhanced care; experience; falls; health care availability; health care delivery; health care quality; health care service; health care service utilization; improved; improved outcome; innovation; medical specialties; member; mortality; payment; policy recommendation; programs; tool; tool development

Background: [The 2019 US Department of Health and Human Services Advancing American Kidney Health Initiative aims to “improve care coordination…for people living with kidney disease.” Accessing care from multiple systems and insurers can result in lapses in care coordination, and] patients with serious conditions, such as chronic kidney disease (CKD), are especially vulnerable to poorer outcomes from fragmented care. [While Medicaid expansion, as occurred with the Affordable Care Act (ACA),] is effective in improving access to health care and health outcomes for the uninsured, the significant number of Veterans enrolled in VA (who already have access to comprehensive care) who gained access to Medicaid with expansion face increased risk of care fragmentation. Increased use of non-VA care as a result of the MISSION Act poses similar risks.] Significance/Impact: As more Veterans access care from a mixture of VA and non-VA sources, VA needs to adopt strategies for cross-system care coordination to ensure effective and efficient care for Veterans. This requires understanding how Veterans utilize care when multiple options are available. Patients with advanced CKD have highly complex care needs. Lack of well-coordinated care may increase unnecessary care and worsen outcomes for such patients. Examining use and outcomes data will illustrate multiple aspects of access and care coordination for Veterans with chronic conditions and anticipates implementation of the MISSION Act. Innovation: [That some states opted out of ACA Medicaid expansion allows for a natural experiment where changes in quality of care and utilization over time can be compared between states that did and did not expand Medicaid. The team will use VA, Medicare, and recently-released post-expansion Medicaid claims data to evaluate how Medicaid expansion influences Veteran choices of health system use and CKD treatment.] Specific Aims: Aim 1: To determine the characteristics of Veterans and Veterans with CKD who are most likely to enroll in both Medicaid and VA. Aim 2: To determine the impact of dual enrollment on the utilization of health care services for Veterans with advanced CKD and to create a reference tool to enhance coordination for these patients. Aim 3: To evaluate differences in quality of health care and costs among Veterans with advanced CKD in states that have expanded Medicaid and those that have not. Methodology: Claims data [from 17 states (7 that expanded Medicaid in 2014 and 10 that did not) in the Medicaid Analytic eXtract (MAX) file for 2011-2014] are included. A difference-in-difference model will estimate the association of state Medicaid expansion with [changes in Veterans’ dual-enrollment status (VA and Medicaid) and in utilization and outcomes for Veterans with CKD. Utilization analyses will consider outpatient visits, emergency department visits and hospital admissions recorded in VA and Medicaid data. Outcomes to be considered are time-to-mortality, emergent vs. elective initiation of dialysis, and costs to the health care system.] Each analysis contains demographics, comorbidity and illness severity. For all aims, separate models for low-income (Priority 5) Veterans are estimated as a sensitivity check. [In addition, strategies to support enhanced care coordination will be gathered from interviews with renal care teams and organizational leaders then developed into a care coordination reference tool for those who provide care for patients with kidney disease. Input from Veterans and patients will be incorporated at each stage of the interview and reference tool development process. Next Steps/Implementation: Veteran/patient and VA operational (National Kidney Program; Office of Veterans Access to Care) partners will be provided with interim and final findings to guide strategic planning and to inform programs that support optimal care for Veterans with access to multiple sources of care. Results from this project will be of great importance as stakeholders plan for Veteran needs in the form of direct health care services and effective care coordination, and as they make state and national policy recommendations.]

背景：[2019年美国卫生与公共服务部推进了美国肾脏健康 倡议旨在“改善患有肾脏疾病的人的护理协调……”。从事护理 多个系统和确保可以导致护理协调的失误，并且[病情严重的患者 慢性肾脏疾病（CKD）尤其容易受到零散护理结果的较差的影响。 [虽然《平价医疗法案》（ACA）所发生的医疗补助扩展是有效改善访问的 对于未保险的医疗保健和健康成果，弗吉尼亚州的大量退伍军人（谁） 已经可以获得综合护理），他们可以使用扩张面而获得医疗补助 护理的风险分裂。由于《任务法》的增加，非VA护理的使用构成了类似的风险。] 意义/影响力：随着越来越多的退伍军人从VA和非VA来源的混合物获得护理，VA需要 采用跨系统护理协调的策略，以确保对退伍军人的有效和有效的护理。这 需要了解当可用多个选项时退伍军人如何利用护理。患者患者 CKD有高度复杂的护理需求。缺乏协调良好的护理可能会增加不必要的护理，并且 此类患者的结果恶化。检查使用和结果数据将说明访问的多个方面 以及对具有慢性条件的退伍军人的护理协调，并预计执行《任务法》。 创新：[一些州选择退出ACA医疗补助扩张允许进行自然实验，其中 随着时间的推移，可以比较的护理质量和利用质量可以比较 扩大医疗补助。该团队将使用VA，Medicare和最近发行的膨胀后Medicaid索赔数据 评估医疗补助的扩张如何影响老兵对卫生系统使用和CKD治疗的选择。] 具体目的：目标1：确定与CKD的退伍军人和退伍军人的特征 可能会参加医疗补助和VA。目标2：确定双重入学人数对利用的影响 具有高级CKD的退伍军人的医疗保健服务，并创建一个参考工具来增强协调 对于这些患者。目标3：评估与退伍军人的医疗保健质量和成本差异 在扩大医疗补助和没有扩大医疗补助的州的高级CKD。 方法论：索赔数据[来自17个州（2014年扩大了医疗补助的7个，没有10个州） 包括2011 - 2014年的医疗补助分析提取物（MAX）文件。差异差异模型将估计 国家医疗补助协会扩展协会与退伍军人双重注册状况的变化（VA和 Medicaid）以及CKD退伍军人的利用率和结果。利用分析将考虑门诊 VA和医疗补助数据中记录的访问，急诊务访问和住院。结果 被认为是验尸，紧急与透析的选修倡议以及医疗保健费用 ]每个分析都包含人口统计学，合并症和疾病严重性。对于所有目标，单独的模型 对于低收入（优先5），退伍军人被估计为灵敏度检查。 [此外，支持的策略 加强护理协调将从肾脏护理团队和组织领导者的访谈中收集 然后为那些为肾脏患者提供护理的人开发成护理协调参考工具 疾病。退伍军人和患者的输入将在访谈和参考工具的每个阶段合并 发展过程。 下一步/实施：老兵/患者和VA操作（国家肾脏计划；办公室 退伍军人获得护理）将提供临时和最终调查结果，以指导战略计划 并告知支持为退伍军人提供最佳护理的计划，并获得了多种护理来源。结果 作为利益相关者计划以直接健康的形式，从这个项目中，将非常重要 护理服务和有效的护理协调，并提出州和国家政策建议。]