基于价值的医疗补助支付政策对大量严重精神疾病患者群体护理质量的早期影响

摘要(中文译文)

在美国，包括纽约州在内的多个州已采用医疗补助基于价值的支付（VBP）政策，以提高医疗质量并减少支出。然而，这些政策对具有高行为健康需求的弱势医疗补助受益人（包括严重精神疾病（SMI）患者）的影响尚不清楚。为通过考察纽约州2017年实施的VBP政策对成年SMI受益人所接受医疗质量的早期影响，为改善医疗补助资助医疗服务价值的政策努力提供依据，我们开展了一项回顾性队列研究，以考察VBP政策与成年医疗补助SMI受益人医疗质量之间的关联。我们采用双重差分模型，比较VBP实施前时期（2014—2016年）及实施后满一年（2018年）暴露于VBP与未暴露于VBP的受益人。质量评估采用10项经过验证且与SMI相关的指标，涵盖精神卫生保健质量（例如，精神分裂症患者抗精神病药物充分依从性、精神疾病住院后30天随访）、躯体医疗保健质量（例如，使用抗精神病药物的精神分裂症或双相障碍患者糖尿病筛查；综合性糖尿病护理、眼科检查）以及整体医疗保健质量（全因再入院）。所有结局模型均对同期政策进行了调整，急性护理指标模型还对照护需求变量进行了调整。我们的多样化队列包括172,420人年的SMI患者，其中28.5%暴露于VBP。最大的诊断组为精神分裂症和双相障碍（分别为42.2%和41.3%）。暴露于VBP与未暴露于VBP的受益人在大多数特征上存在差异，未暴露者相对更年轻、多样性较低且更健康。调整协变量后，与未暴露于VBP组相比，VBP暴露仅与10项质量指标中的两项变化相关：精神分裂症患者抗精神病药物充分依从性提高1.8个百分点（95% CI，0.5-3.2），使用抗精神病药物的精神分裂症或双相障碍患者糖尿病筛查下降1.4个百分点（95% CI，-2.6至-0.1）。实施一年后，这项涉及不同程度提供方风险承担的医疗补助VBP政策对该州SMI受益人的质量影响甚少，一项为正面、一项为负面。我们的研究首次采用多项经过验证的精神卫生、躯体及整体医疗保健质量指标考察VBP的质量影响，但存在一些局限性，包括无法排除随时间变化的未测量混杂因素，也无法分离风险安排类型（单侧与双侧）的影响或VBP合同中可能纳入的与SMI照护质量相关的指标组合的影响。此外，由于观察期相对较短，我们的研究可能未捕捉到VBP政策的全部影响。寻求利用VBP改善SMI照护质量的政策制定者可考虑可能有助于实现该目标的VBP政策特征，例如，对提供临床整合照护的激励措施以及在合同中纳入与SMI相关的质量指标。未来研究应旨在证实并拓展我们的发现。

Abstract

In the US, several states including New York State (NYS) have adopted Medicaid value-based payment (VBP) policies to improve healthcare quality and reduce spending. However, the impacts of these policies on vulnerable Medicaid beneficiaries with high behavioral health needs including those with serious mental illness (SMI) are unknown. To inform policy efforts to improve the value of Medicaid-funded care by examining the early impacts of NYS's VBP policy implemented in 2017 on the quality of healthcare received by adult beneficiaries with SMI. We conducted a retrospective cohort study to examine the association of the VBP policy with healthcare quality among adult Medicaid beneficiaries with SMI. We estimated difference-in-differences models comparing VBP-exposed and unexposed beneficiaries during the period preceding VBP implementation (2014-2016) and in 2018, a full year following implementation. Quality was assessed with 10 validated and SMI-relevant measures of mental healthcare quality (e.g., adequate Adherence to Antipsychotic Medications for Individuals with Schizophrenia, and Follow-up after Hospitalization for Mental Illness, 30-day), physical healthcare quality (e.g., Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are using Antipsychotic Medications; Comprehensive Diabetes Care, Eye Exam), and overall healthcare quality (All-Cause Readmissions). Models for all outcomes adjusted for concurrent policies, and models for acute care measures also adjusted for need variables. Our diverse cohort included 172,420 person-years with SMI, with 28.5% VBP-exposed. The largest diagnostic groups were schizophrenia and bipolar disorder (42.2% and 41.3%, respectively). The VBP-exposed and unexposed beneficiaries differed on most characteristics, with the unexposed being slightly younger, less diverse, and healthier relative to the VBP-exposed. After adjusting for covariates, VBP-exposure was associated with changes in only two of the 10 quality measures compared with the VBP-unexposed group: a 1.8- percentage-point (pp) increase in adequate Adherence to Antipsychotic Medications for Individuals with Schizophrenia (95% CI, 0.5-3.2) and a 1.4-pp decrease (95% CI, -2.6 to -0.1) in Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are using Antipsychotic Medications. A year following its implementation, a Medicaid VBP policy that involved varying degrees of provider risk-bearing had few quality impacts, one positive and one negative, among the state's beneficiaries with SMI. Our study, the first to examine VBP quality impacts with several validated measures of mental, physical, and overall healthcare quality, has some limitations, including that we cannot rule out time-varying unmeasured confounding, nor can we isolate the effects of type of risk arrangement (one-sided versus two-sided) or the mix of measures potentially associated with quality of SMI care included in the VBP contracts. Additionally, our study may not have captured the full impacts of the VBP policy due to our relatively short observation period. Policymakers seeking to use VBP to improve quality of SMI care may consider VBP policy features likely to facilitate achieving this goal, for example, incentives for delivering clinically integrated care and inclusion in contracts of SMI-relevant quality measures. Future studies should be designed to confirm and extend our findings.

如何引用

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