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: 10833998
• 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/10833998
• 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年美国卫生与公众服务部推进美国肾脏健康 该倡议旨在“改善肾病患者的护理协调”。 多个系统和保险公司可能会导致护理协调失误，并且]病情严重的患者， 例如慢性肾病（CKD），特别容易因分散的护理而导致较差的结果。 [虽然医疗补助的扩展，如《平价医疗法案》(ACA) 中所发生的那样，] 可有效改善医疗服务的获取 对于未参保者的医疗保健和健康结果，大量退伍军人加入 VA（他们 已经获得全面护理）谁获得医疗补助并扩大面增加 由于《使命法案》而增加使用非 VA 护理也带来了类似的风险。 意义/影响：随着越来越多的退伍军人从 VA 和非 VA 来源获得护理，VA 需要 采用跨系统护理协调策略，确保对退伍军人有效且高效的护理。 需要了解退伍军人在有多种选择的情况下如何利用护理。 慢性肾病的护理需求非常复杂，缺乏协调一致的护理可能会增加不必要的护理和治疗。 检查此类患者的使用情况和结果数据将说明访问的多个方面。 以及对患有慢性病的退伍军人的护理协调，并预计《使命法案》的实施。 创新：[一些州选择退出 ACA 医疗补助计划扩展，从而可以进行自然实验，其中 可以比较提供和未提供护理的国家之间随着时间的推移护理质量和利用率的变化 扩大医疗补助计划。该团队将使用 VA、医疗保险和最近发布的医疗补助计划扩大后的索赔数据。 评估医疗补助扩展如何影响退伍军人对卫生系统使用和 CKD 治疗的选择。] 具体目标： 目标 1：确定最常罹患 CKD 的退伍军人和患有 CKD 的退伍军人的特征 可能同时加入 Medicaid 和 VA 目标 2：确定双重加入对利用的影响。 为患有晚期 CKD 的退伍军人提供医疗保健服务，并创建一个参考工具来加强协调 目标 3：评估患有以下疾病的退伍军人之间的医疗保健质量和费用差异。 在已扩大医疗补助计划和未扩大医疗补助计划的州，慢性肾病进展顺利。 方法论：索赔数据[来自 17 个州（7 个州在 2014 年扩大了医疗补助计划，10 个州没有扩大医疗补助计划） 包括 2011-2014 年医疗补助分析提取 (MAX) 文件] 将使用双重差分模型进行估算。 州医疗补助扩张与[退伍军人双重注册身份（VA 和 医疗补助）以及患有 CKD 的退伍军人的利用率和结果利用率分析将考虑门诊患者。 VA 和医疗补助数据中记录的就诊、急诊就诊和住院情况。 考虑死亡时间、紧急透析与选择性透析以及医疗保健费用 系统。] 每个分析都包含人口统计数据、合并症和疾病严重程度，针对所有目标、单独的模型。 对于低收入（优先级 5）退伍军人进行敏感性检查[此外，支持策略。 将通过与肾脏护理团队和组织领导者的访谈来收集加强的护理协调 然后发展成为为肾病患者提供护理的护理协调参考工具 退伍军人和患者的意见将纳入访谈和参考工具的每个阶段。 发展过程。 后续步骤/实施：退伍军人/患者和 VA 运作（国家肾脏计划；办公室 退伍军人获得护理）合作伙伴将获得中期和最终调查结果，以指导战略规划 并告知支持退伍军人最佳护理的计划，以获得多种护理来源的结果。 该项目的成果将非常重要，因为利益相关者以直接健康的形式规划退伍军人的需求 护理服务和有效的护理协调，以及他们提出州和国家政策建议。]