Joint Effect of Malpractice Risk and Financial Incentives on Cardiac Testing

医疗事故风险和经济激励对心脏检查的联合影响

基本信息

批准号：
9114647
负责人：
Bernard S Black
金额：
$ 55.15万
依托单位：
GEORGE WASHINGTON UNIVERSITY
依托单位国家：
美国
项目类别：
财政年份：
2013
资助国家：
美国
起止时间：
2013-08-05 至 2018-07-31
项目状态：
已结题

来源：
https://reporter.nih.gov/project-details/9114647
关键词：
Accounting Acute myocardial infarction Address Adopted Affect American Angiography Area Cardiac Cardiac Catheterization Procedures Cardiology Caring Cessation of life Clinical Control Groups Coronary Arteriosclerosis Defensive Medicine Echocardiography Economics Ensure Epidemiology Face Failure Fee-for-Service Plans Floor Frequencies Fright Goals Growth Health Health Care Costs Health Policy Healthcare Hospitals Image Incentives Individual Inpatients Insurance Carriers Intervention Joints Laws Lead Left Legal Location Malpractice Managed Care Medical Medicare Modeling Myocardial perfusion Nature Outcomes Research Outpatients Patient risk Patient-Focused Outcomes Patients Pattern Physicians Policies Policy Maker Provider Quality of Care Research Research Design Research Personnel Risk Savings Shock Societies Stress Echocardiography Stress Tests Testing Thallium Myocardial Perfusion Imaging Stress Test Tort Training Treatment outcome United States United States Centers for Medicare and Medicaid Services base behavioral outcome capitate bone clinical practice cost falls financial incentive health care cost/financing medical malpractice multidisciplinary patient expectation payment policy implication programs research study response success

项目摘要

DESCRIPTION (provided by applicant): Cardiac testing is a major contributor to health care costs and cost growth. There is substantial evidence that cardiac testing is overused. Two potential reasons for overuse are test profitability to providers and their fear of medical malpractice liability. A central goal of our study is to examine how liability risk and financial incentives, individually and jointly influence cardiac testing rates and patient outcomes. No prior study examines the impact of either factor on cardiac testing rates; no prior study in any area of medical care studies the interactions between liability risk and financial incentives. These interactions are likely to be important. If testing is profitable, both malpractice risk and profitability could induce test overuse. In contrast, if testing is unprofitable, malpractice risk could provide a "floor" on testing rates, and thus limit underuse. We will study these issues, relying on external shocks to malpractice risk and reimbursements as a basis for credible causal inference. For malpractice, we will rely on state reforms over the last decade, during which nine states adopted new damage caps. For reimbursements, we will rely on large cuts by the Centers for Medicare and Medicaid Services (CMS), beginning in 2010, to reimbursement for outpatient stress testing. The stakes for these cuts are large. If these cuts curb overuse, CMS would achieve billions of dollars of annual savings and might adopt similar cuts elsewhere. However, spending could rise if testing moves from outpatient to inpatient settings, or providers substitute more expensive tests which did not face cuts. Additionally, the cuts could harm patients if testing rates fall below the optimal level. To assess the impact of malpractice risk, w will study states that adopted tort reforms, using other states as a control group. For reimbursement cuts, we will study cardiac testing within Medicare fee-for-service, using Medicare Advantage patients as the control group. The project aims are to: (1) assess the impact of malpractice reforms alone on testing rates; (2) assess the impact of reimbursement cuts alone on testing rates and locations; (3) examine the interaction between malpractice risk and reimbursement cuts; and (4) assess how malpractice risk and reimbursement levels individually and jointly affect patient outcomes. Understanding the combined impact of these reforms is critical to ensure quality care for the nearly 20 million Americans with coronary artery disease (CAD) and the many more who are tested for it each year. Moreover, large scale experiments in both medical malpractice and payment reform are underway, not limited to cardiac care. Our research can inform policy decisions in several areas, including: (i) can malpractice liability limit the risks of undertreatment that previously tainted "managed care" and might undermine the success of "accountable care"?; (ii) can reimbursement cuts, such as those made to outpatient stress testing limit test overuse, or will they have unintended consequences - either raising cost or degrading care quality?; and (iii) how does the optimal level of malpractice risk vary with the nature of provider reimbursement?

描述（由申请人提供）：心脏测试是造成医疗保健成本和成本增长的主要贡献者。有大量证据表明心脏测试过度使用。过度使用的两个潜在原因是对提供者的测试盈利能力及其对医疗事故责任的恐惧。我们研究的一个核心目的是研究责任风险和经济激励措施如何单独和共同影响心脏测试率和患者结果。没有先验研究检查了这两个因素对心脏测试率的影响；在医疗研究的任何领域都没有先前研究责任风险与经济激励措施之间的相互作用。这些相互作用可能很重要。如果测试是有利可图的，则渎职风险和盈利能力都可能导致测试过度使用。相比之下，如果测试是无利可图的，则渎职风险可能会在测试率上提供“地板”，从而限制不使用。我们将研究这些问题，依靠外部冲击来渎职风险和报销作为可信因果推断的基础。对于渎职行为，我们将依靠过去十年的国家改革，在此期间，九个州采用了新的损害上限。对于报销，我们将依靠2010年开始的Medicare和Medicaid Services（CMS）的大量削减，以偿还门诊应力测试。这些切口的赌注很大。如果这些削减措施遏制过度使用，CMS将获得数十亿美元的每年储蓄，并可能在其他地方采取类似的削减。但是，如果测试从门诊转移到住院设置，或者提供者替代了不面临切割的更昂贵的测试，则支出可能会上升。此外，如果测试率低于最佳水平，则削减可能会损害患者。为了评估渎职风险的影响，W将研究采用其他州作为对照组的国家。为了减少报销，我们将使用Medicare Advantage患者作为对照组在医疗保险费用中学习心脏测试。该项目的目的是：（1）评估单独改革对测试率的影响；（2）评估单独削减报销对测试率和位置的影响；（3）检查渎职风险和赔偿削减之间的相互作用；（4）评估渎职的风险和报销水平如何单独地影响患者的预后。了解这些改革的综合影响对于确保近2000万美国冠状动脉的美国人的优质护理至关重要疾病（CAD）和每年接受测试的许多人。此外，正在进行医疗事故和付款改革的大规模实验，而不仅限于心脏护理。我们的研究可以在多个领域提供政策决定，包括：（i）渎职责任可以限制以前污染“托管护理”的不足的风险，并可能破坏“责任心护理”的成功？（ii）可以报销削减，例如为门诊应力测试限制测试过度使用的削减，还是会产生意想不到的后果 - 提高成本或降解护理质量？（iii）最佳弊端风险水平与提供商报销的性质有何不同？