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.

项目摘要 在抗逆转录病毒疗法（ART）中，艾滋病毒（PWH）患者的预期寿命大大增加 时代。因此，Medicare计划预计PWH衰老的“银海啸”。那里 对艾滋病毒将如何影响治疗决策，护理质量和临床结果的重大关注 较旧的PWH，具有与年龄相关的多种疾病，例如阿尔茨海默氏病和相关痴呆症（ADRD）， 心血管疾病（CVD）和精神疾病。尽管有这些担忧，我们目前缺乏国家 对PWH的质量和结果如何随着时间的推移或关键而改变的质量和结果如何变化 影响护理的患者，药物计划，市场，社区和政策因素。护理质量的关注是 在历史上边缘化的人群中，尤其是在基线时经历较差的护理质量的人， 包括种族和少数民族，人口粗糙，低收入成年人有资格获得医疗补助和 Medicare。一项旨在提高医疗保险计划中老年人质量的国家战略是扩展 替代支付模型（APM），包括负责任的护理组织（ACO），其中一组 医疗保健提供者负责分配的患者的总成本和护理质量，并捆绑 付款模型（BPM），可以在接受特定临床发作后促进成本降低。 尽管APM已获得适度的节省和Medicare受益人质量的改善 通常，没有经验数据评估APM是否对PWH有效。有人担心 这些模型中的质量和成本基准可能会导致APM中的临床医生避免高危患者 PWH，或在服务PWH时，由于积极的成本控制工作，限制了必要的护理。作为联邦 政府扩大了APM，我们必须了解APM对PWH健康的影响至关重要。在这个 研究，我们将使用国家，纵向数据（2005年至2025年）购买三个目标。 AIM 1将评估变化 与没有艾滋病毒的匹配人群相比，PWH的护理和健康成果的质量 还将确定与患者，计划，市场，临床特殊和社区级别有关的因素 更好的质量，公平和改善的结果。 AIM 2将使用准实验研究设计来确定 Medicare ACO（最大的Medicare APM）对PWH的护理和健康成果的影响。 最后，AIM 3将确定Medicare BPM是第二大APM，提高质量还是更差，并且 PWH的结果。这项研究的结果将对关键因素提供国家的观点，包括 D部分毒品福利设计，关于年龄资格的PWH的护理质量和健康成果 Medicare。我们还提出了第一项评估APM对PWH的影响的国家研究。我们的工作将 信息旨在改善PWH的质量和健康成果的国家临床，公共卫生和政策努力 在Medicare计划中，包括在APM下考虑对PWH的特定政策修改。