兰德-全球支付行业进展报告（英文）-2018.9-196页-1mb

Summary of the Global Payment Program (GPP) Midpoint Evaluation

Core Content

The Global Payment Program (GPP) is a pilot initiative launched by the California Department of Health Care Services (DHCS) in July 2015. The program aims to improve care for the remaining uninsured individuals by transforming the existing Medicaid Disproportionate Share Hospital (DSH) and Safety Net Care Pool (SNCP) funds into a broader payment system that supports a wider range of services, including non-traditional services such as patient education, case management, and nurse advice lines. This evaluation report is part of a broader assessment of the GPP's impact on primary care, data collection, and care coordination, as well as its effect on non-inpatient non-emergent service utilization.

Main Research Questions and Hypotheses

The midpoint evaluation focuses on two key research questions:

1. Did the GPP allow PHCS to build or strengthen primary care, data collection and integration, and care coordination to deliver care to the remaining uninsured?
2. Across the majority of PHCS, did the utilization of non-inpatient non-emergent services increase?

The evaluation also examines three hypotheses:

• Hypothesis 1: PHCS have built and strengthened primary care, data collection, and care coordination since the GPP began.
• Hypothesis 2: Most PHCS have increased the utilization of non-inpatient non-emergent services.
• Hypothesis 3: PHCS are establishing a strong foundation to deliver care to the remaining uninsured.

Key Findings

PHCS Adoption of Strategies

• PHCS leaders and teams rated improving access to care and enhancing data capture as their top priorities for meeting GPP goals.
• They also emphasized the importance of increasing infrastructure, aligning organizational culture with GPP goals, and transforming workforce roles.
• PHCS adopted a mean of 38 out of 49 health system improvement strategies, supporting the idea that they have been actively working to meet GPP objectives.
• These strategies were clustered into six domains of health system transformation, including primary care, data collection, care coordination, and others.

Service Provision and Utilization

• PHCS reported providing a mean of 33 out of 50 GPP patient care services, with significant variation across systems.
• Category 1 (outpatient services in traditional settings) had the highest utilization, with 89% of 13 services being offered.
• Category 2 (complementary patient support and care services) had 64% of 17 services offered, with health education being the only service provided by all 12 PHCS.
• Category 3 (technology-based outpatient services) had 39% of 11 services offered, with no service provided by all PHCS.
• Category 4 (inpatient services) had 69% of 9 services offered, including two services used by all PHCS.

Service Modifications

• PHCS made modifications to their service offerings, including reductions, increases, and development of new services.
• Eleven services remained unchanged, while one service in category 4 was reduced.
• 27 out of 48 possible service modifications were associated with increases in existing services, and 28 services were newly developed.
• Non-traditional services were more likely to be increased or newly developed than traditional ones, suggesting a shift in service delivery models.

Evaluation Methods and Limitations

• The evaluation used a mixed-methods approach, combining survey data and utilization data from the first two program years.
• Descriptive statistical methods were primarily used, with no formal hypothesis testing due to the lack of a control group and the small number of participating PHCS.
• The data included 24 months of utilization trends and cost data for the baseline year and program year 1.

Key Information

• The GPP is designed to reimburse providers for non-traditional services and settings, which can include preventive care, mental health services, and patient education.
• Point-based payment methodology is used to determine GPP payments, which are reconciled annually and paid quarterly based on pre-established thresholds.
• The GPP provides greater predictability in funding compared to previous models, which were based on pro rata distribution of Medi-Cal and uncompensated care costs.
• The evaluation highlights variations in PHCS approaches to implementing the GPP, suggesting that local context and resources influence the type and extent of changes made.

Conclusion

The GPP has enabled PHCS to enhance their infrastructure and care processes, with a focus on primary care, data integration, and care coordination. While non-inpatient non-emergent service utilization has increased, the degree of change varies across PHCS. The program has also led to the development of new services and expansion of existing ones, particularly in non-traditional categories. The evaluation provides insights into the effectiveness of the GPP and supports further refinements in its implementation and impact assessment.