PROJECT SUMMARY (See instructions): Budgetary issues have intensified the focus on improving efficiency in publicly funded health programs. Yet Medicare and Medicaid insure some of the most ill or disabled patients, who are also some of the most expensive. Proposals to address costs create incentives to increase care coordination and accountability for the continuum of care. Realizing spending reductions in this population, however, needs to be balanced with assuring quality for a group at high risk for mortality, functional loss, and decline in quality of life. The overarching goal of this project is to study how fragmentation of care, and the reverse, increased integration, vary with cost and quality of care for high need beneficiaries, including patients dually eligible for Medicare and Medicaid. Efficient care for high need patients may require a broad network that includes multiple physician specialties, acute care hospital, and other types of inpatient care (psychiatric, long term acute hospital or nursing home). In previous work, we have developed an actionable unit - the physician-hospital network - which links Medicare beneficiaries to the specific physicians and hospitals that deliver the majority of their care. We seek to broaden this approach with respect to high need patients using observational cohort methods. We will use national Medicare, Medicaid and Minimum Data Set data to address major gaps in the literature. In Aim 1, we will define networks of healthcare providers for high need patients, and how patients, care, and spending are distributed within and across these networks. In Aim 2, we will test how cost and quality of care for high need patients vary with system (i.e. provider network and region) characteristics. And in Aim 3, we will take advantage of changes in the marketplace to study how cost and quality measures change as health systems formally integrate. The long-term impact of this work will be to provide rigorous information about who can reasonably be held accountable for the care of high need patients and identify the points of leverage for improving outcomes.
PROJECT SUMMARY (See instructions): We have proposed five projects that together address many of the shortcomings in our understanding of how to measure, study and improve efficiency in healthcare. Core B is responsible for data management and analytic support for the data on which the five projects rest. To understand the causes and consequences of differences in the efficiency of healthcare, it is crucial to have: (1) a comprehensive database with sufficient power to characterize detailed patterns of healthcare utilization at the regional, hospital, physician and network levels, (2) a broad array of additional measures drawn from diverse sources that can augment these data, (3) the analytic capacity and oversight to ensure the timely preparation of analytic datasets, and (4) appropriate access to these resources for other investigators. We plan first to maintain a comprehensive and secure database of administrative data including Medicare and Medicaid enrollment files, claims records, and supplementary files. Second, we hope to obtain and manage additional data files required for this P01 and to develop subproject-specific analytic files. We will obtain data from a variety of sources, including the American Board of Internal Medicine, the Minimum Data Set of nursing home care, and Michigan and Texas Blue Cross Blue Shield data. Third, we seek to maintain a computing infrastructure and procedures capable of managing a high volume of patient identifiable, confidential data while ensuring timely and appropriate access to authorized investigators. And finally, we plan to make the research files developed under this P01 available to the research community to the extent permissible under law.
