Improving Healthcare Quality and Equity For Older Adults with HIV Under Value-Based Care Models

在基于价值的护理模式下提高艾滋病毒感染者的医疗质量和公平性

• 批准号: 10762522
• 负责人: Jose Francisco Figueroa
• 金额: $ 76.77万
• 依托单位: HARVARD SCHOOL OF PUBLIC HEALTH
• 依托单位国家: 美国
• 财政年份: 2023
• 资助国家: 美国
• 起止时间: 2023-08-15 至 2028-04-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10762522
• 关键词: Acquired Immunodeficiency Syndrome; Admission activity; Adult; Affect; Age; Aging; Alzheimer' s disease related dementia; Benchmarking; Biological; Black race; Cardiovascular Diseases; Caring; Chronic; Clinical; Communicable Diseases; Communities; Complex; Cost Control; Data; Deductibles; Disparity; Elderly; Eligibility Determination; Enrollment; Equity; Evaluation; Federal Government; Goals; Government; Guidelines; HIV; Health; Health Personnel; Health Services; Home; Hospitals; Inequity; Latino Population; Lead; Life Expectancy; Longitudinal cohort; Low income; Marketing; Medicare; Medicare/Medicaid; Mental disorders; Modeling; Modification; Older Population; Outcome; Patient Care; Patients; Persons; Pharmaceutical Preparations; Policies; Policy Maker; Population; Predictive Factor; Public Health; Public Policy; Quality of Care; Quasi-experiment; Recommendation; Research; Research Design; Research Personnel; Risk; Rural Population; Savings; Services; Silver; Specialist; Strategic vision; Subgroup; Time; Tsunami; Work; accountable care organization; acute care; antiretroviral therapy; beneficiary; bundled payment; care costs; community-level factor; comorbidity; copayment; cost; design; dual eligible; ethnic minority; experience; financial incentive; frailty; health care quality; health care service utilization; high risk; improved; improved outcome; marginalization; marginalized population; medical specialties; mortality; multidisciplinary; multiple chronic conditions; novel; payment; poor health outcome; programs; racial minority; social

Project Summary Life expectancy for people living with HIV (PWH) has increased substantially in the antiretroviral therapy (ART) era. Consequently, the Medicare program is anticipating a “silver tsunami” of PWH aging into program. There are substantial concerns about how HIV will affect treatment decisions, quality of care, and clinical outcomes of older PWH with age-associated multimorbidity, like Alzheimer’s disease and related dementias (ADRD), cardiovascular disease (CVD), and mental illness. Despite these concerns, we currently lack a national, comprehensive understanding of how quality and outcomes have changed for PWH over time, or the key patient, drug plan, market, community, and policy factors that influence care. Quality of care concerns are especially salient among historically marginalized populations that experience worse care quality at baseline, including racial and ethnic minorities, rural populations, and low-income adults dual-eligible for Medicaid and Medicare. A national strategy aimed at improving quality for older adults in the Medicare program is expansion of alternative payment models (APMs), including Accountable Care Organizations (ACOs), in which a group of healthcare providers take responsibility for assigned patients’ total costs and quality of care, and Bundled Payment Models (BPMs), which encourage cost reductions following admissions for specific clinical episodes. Although APMs have achieved modest savings and improvements in quality for Medicare beneficiaries generally, there is no empirical data evaluating whether APMs are effective for PWH. There are concerns that the quality and cost benchmarks in these models may lead clinicians in APMs to avoid high-risk patients like PWH, or when serving PWH, to limit necessary care due to aggressive cost-containment efforts. As the federal government expands APMs, it is critical that we understand the impact of APMs on the health of PWH. In this study, we will use national, longitudinal data (2005 to 2025) to pursue three aims. Aim 1 will evaluate changes in the quality of care and health outcomes among PWH compared to a matched population without HIV, and it will also identify the patient-, plan-, market-, clinician specialty-, and community-level factors associated with better quality, equity, and improved outcomes. Aim 2 will use a quasi-experimental study design to determine the impact of Medicare ACOs, the largest Medicare APM, on the quality of care and health outcomes of PWH. Finally, Aim 3 will determine whether Medicare BPMs, the second largest APM, improve or worsen quality and outcomes for PWH. Findings from this study will offer a national perspective on the key factors, including the Part D Drug Benefit design, on quality of care and health outcomes of PWH following age-eligibility for Medicare. We also propose the first national study to evaluate the impact of APMs on PWH. Our work will inform national clinical, public health and policy efforts aimed at improving quality and health outcomes of PWH in the Medicare program, including consideration of specific policy modifications for PWH under APMs.

项目概要 抗逆转录病毒治疗 (ART) 显着延长了艾滋病毒感染者 (PWH) 的预期寿命 研究表明，医疗保险计划预计将出现“银发海啸”，将 PWH 老龄化纳入计划。 关于艾滋病毒将如何影响治疗、护理质量和临床结果的决策是重大问题 患有与年龄相关的多种疾病的老年 PWH，例如阿尔茨海默病和相关痴呆症 (ADRD)， 尽管存在这些担忧，但我们目前缺乏一个全国性的、 全面了解随着时间的推移，PWH 的质量和结果如何变化，或者关键 影响护理质量的患者、药物计划、市场、社区和政策因素是。 在基线时护理质量较差的历史悠久的人群中尤其突出， 包括种族和族裔少数群体、农村人口以及具有医疗补助和医疗补助双重资格的低收入成年人 医疗保险是一项旨在提高老年人医疗保险计划质量的国家战略。 替代支付模式 (APM)，包括责任医疗组织 (ACO)，其中一组 医疗保健提供者对指定患者的总成本和护理质量负责，并且捆绑 支付模型 (BPM)，鼓励在特定临床事件入院后降低成本。 尽管 APM 为 Medicare 受益人实现了适度的节省并提高了质量 一般来说，没有经验数据评估 APM 对 PWH 是否有效。 这些模型中的质量和成本基准可能会导致 APM 的捍卫者避免像这样的高风险患者 PWH 或在为 PWH 服务时，由于联邦采取积极的成本控制措施而限制必要的护理。 在政府扩大 APM 的同时，我们了解 APM 对感染者健康的影响至关重要。 研究中，我们将使用国家纵向数据（2005 年至 2025 年）来实现三个目标，目标 1 将评估变化。 与未感染艾滋病毒的匹配人群相比，感染者的护理质量和健康结果有所提高，并且 还将确定与相关的患者、计划、市场、临床医生专业和社区层面的因素 目标 2 将使用准实验研究设计来确定更好的质量、公平性和更好的结果。 Medicare ACO（最大的 Medicare APM）对 PWH 的护理质量和健康结果的影响。 最后，目标 3 将确定第二大 APM Medicare BPM 是否提高或恶化了质量和 这项研究的结果将为关键因素提供全国视角，包括 D 部分药物福利设计，关于符合年龄资格的感染者的护理质量和健康结果 我们还提出了第一项全国性研究来评估 APM 对 PWH 的影响。 为旨在提高感染者卫生保健质量和健康结果的国家临床、公共卫生和政策工作提供信息 医疗保险计划，包括考虑 APM 下针对 PWH 的具体政策修改。