Learning from Medicare Payment Reform: Economic Effects of ACO Incentives

DESCRIPTION (provided by applicant): Policymakers have embraced pay-for-performance and shared savings/risk models to improve healthcare and moderate cost growth in publically funded healthcare programs. There is a strong commitment by both public and private payers to move from volume-based payment toward payment models rewarding value. The Affordable Care Act authorized Medicare to contract with accountable care organizations (ACOs), networks of providers responsible for the health care of a defined population. While implementation of these programs is moving forward rapidly, there is little evidence to guide whether these programs have the potential to yield real cost savings while improving quality. Under the R21 phase of this application, we will complete an evaluation of Medicare's Physician Group Practice Demonstration, a joint pay-for-performance and shared savings effort in 10 multi-specialty physician groups. The Physician Group Practice Demonstration reforms are similar in many respects to the currently legislated ACO reforms, and thus qualify as the best evidence we have to date of the effects of ACO incentives. Yet beyond bonus payments and quality scores publicly reported for each of the ten sites, little is known about how the incentive scheme affected overall costs, quality or outcomes. Our data analysis begins with a simple difference-in-difference strategy, with local Medicare beneficiaries as controls, to measure the effect of the Demonstration on Medicare payments and quality metrics beyond those measured for payment purposes. We will expand the comparison groups to similar physician practices beyond local controls and will focus on accounting for selection into the program and the role of risk adjustment in study of costs and outcomes. In addition, a major objective of our research will be to develop a structural model of Medicare payment reform incentive schemes, with parameters estimated using outcomes arising from the Physician Group Practice Demonstration, that we believe can explain some part of the heterogeneity observed in provider responses to the PGPD. The milestones for completion of the R21 phase will include development of a theoretical model of ACO incentive schemes, completion of appropriate control groups and estimation of a selection model, specification of appropriate quality and outcome measures, and adequate risk adjustment measures. In the R33 phase of the application, we will apply techniques and models developed in the R21 phase to the Pioneer and Medicare Shared Savings Programs, which will include a greater number of accountable care organization participants and more subtleties in incentive design.

描述（由申请人提供）：政策制定者采用了绩效的薪水和共同的储蓄/风险模型，以改善公共资助的医疗保健计划中的医疗保健和中等成本增长。公共付款人和私人付款人都做出了坚定的承诺，即从基于数量的付款转向付款模型奖励价值。 《负担得起的护理法》授权Medicare与负责任的护理组织（ACO）合同，该组织的网络，负责确定人口的医疗保健的网络。尽管这些计划的实施正在迅速发展，但几乎没有证据可以指导这些计划是否有可能在提高质量的同时节省实际的成本。在此应用程序的R21阶段，我们将完成对Medicare的医师团体实践示范的评估，表现的联合薪酬和共同的储蓄努力在10个多专科医师组中。在许多方面，医师团体实践示范改革与当前立法的ACO改革相似，因此有资格作为我们必须及早获得ACO激励措施影响的最佳证据。然而，除了奖金付款和质量分数超出了十个站点中的每个站点的公开报告，对激励计划如何影响整体的每个网站都知之甚少 成本，质量或结果。我们的数据分析始于一个简单的差异策略，并以当地的医疗保险受益人作为控制，以衡量演示对医疗保险付款和质量指标的影响，而不是用于付款目的的质量指标。我们将将比较组扩展到除本地控制之外的类似医师实践，并将集中于对该计划进行选择以及风险调整在成本和成果研究中的作用。此外，我们的研究的一个主要目标是开发一种Medicare支付改革激励计划的结构模型，并使用由医师小组实践演示产生的结果估算的参数，我们相信可以解释在提供者对PGPD的提供者反应中观察到的异质性的某些部分。 R21阶段完成的里程碑将包括开发ACO激励方案的理论模型，完成适当的对照组以及选择模型的估计，适当的质量和结果指标的规范以及适当的风险调整措施。在应用程序的R33阶段，我们将应用R21阶段开发的技术和模型，并将Medicare共享储蓄计划和Medicare共享的储蓄计划，其中包括更多的负责任的护理组织参与者以及激励设计中的更多细微之处。