Turenne Marc N, Hirth Richard A, Pan Qing, Wolfe Robert A, Messana Joseph M, Wheeler John R C
Kidney Epidemiology and Cost Center, University of Michigan, Ann Arbor, Michigan 48103, USA.
Med Care. 2008 Feb;46(2):120-6. doi: 10.1097/MLR.0b013e31815b9d7a.
In developing "pay-for-performance" and capitation systems that provide incentives for improving the quality and efficiency of care, policymakers need to determine which healthcare providers to evaluate and reward.
This study demonstrates methods for determining and understanding the relative contributions of facilities and physicians to the quality and cost of care. Specifically, this study distinguishes levels of variation in resource utilization (RU), based on research to support the development of an expanded Medicare dialysis prospective payment system.
Mixed models were used to estimate the variation in RU across institutional providers, physicians, patients, and months (within patients), after adjusting for case-mix.
The study includes 10,367 Medicare hemodialysis patients treated in a 4.2% stratified random sample of dialysis facilities in 2003.
Monthly RU was measured by the average Medicare allowable charge per dialysis session for separately billable dialysis-related services (mainly injectable medications and laboratory tests) from Medicare claims.
There was financially significant variation in RU across institutional providers and to a lesser degree across physicians, after adjusting for differences in case-mix. The remaining variation in RU reflects unexplained differences across patients that persist over time and transitory fluctuations for individual patients.
The greater variation in RU occurring across dialysis facilities than across physicians is consistent with targeting payments to facilities, but alignment of incentives between facilities and physicians remains an important goal. Similar analytic methods may be useful in designing payment policies that reward providers for improving the quality of care.
在制定“按绩效付费”和人头费制度以激励提高医疗质量和效率时，政策制定者需要确定评估和奖励哪些医疗服务提供者。
本研究展示了确定和理解医疗机构及医生对医疗质量和成本的相对贡献的方法。具体而言，本研究基于支持扩大医疗保险透析前瞻性支付系统发展的研究，区分了资源利用（RU）的变异水平。
在调整病例组合后，使用混合模型估计不同机构提供者、医生、患者和月份（患者内部）之间RU的变异。
该研究纳入了2003年在4.2%分层随机抽样的透析机构中接受治疗的10367名医疗保险血液透析患者。
每月RU通过医疗保险报销的与透析相关的可单独计费服务（主要是注射药物和实验室检查）每次透析疗程的平均医疗保险允许费用来衡量。
在调整病例组合差异后，不同机构提供者之间的RU存在显著的财务差异，医生之间的差异程度较小。RU的剩余差异反映了患者之间持续存在的无法解释的差异以及个体患者的短暂波动。
透析机构之间的RU变异大于医生之间的变异，这与将支付目标对准机构是一致的，但机构和医生之间激励措施的协调仍然是一个重要目标。类似的分析方法可能有助于设计奖励提供者提高医疗质量的支付政策。
