Calman Neil S, Hauser Diane, Chokshi Dave A
Institute for Family Health, New York, New York, USA.
Arch Intern Med. 2012 Apr 9;172(7):584-6. doi: 10.1001/archinternmed.2012.219.
The Affordable Care Act made admirable strides toward the "triple aim" of reducing health care costs, increasing health care quality, and improving the health of the community at large. A key element of reform is the accountable care organization (ACO), which restructures health care delivery such that networks of providers are held responsible for a group of patients they serve. The recently announced Medicare ACO program lays the foundation for 2 of its 3 major goals by allowing ACOs to share in any cost savings, provided they meet quality criteria. Yet it seems that the public health goals of accountable care-arguably the most important of the 3-have been left behind. To better address public health goals, we propose a novel method for quality reporting within ACOs: introducing an "expanded denominator" that attributes patients to a health system if they have ever been seen within the system. An expanded denominator would ensure that ACOs are held accountable not only for patients already engaged in primary care but also for patients with fragmented care and high-risk community members not receiving adequate care. Ultimately, payment reform in Medicare, and potentially Medicaid, must support this new approach to quality measurement for it to have lasting ramifications.
《平价医疗法案》在实现降低医疗成本、提高医疗质量以及改善广大社区健康状况这一“三重目标”方面取得了令人钦佩的进展。改革的一个关键要素是 accountable care organization（ACO，可问责医疗组织），它对医疗服务的提供进行重组，使医疗服务提供者网络对其所服务的一组患者负责。最近宣布的医疗保险 ACO 计划通过允许 ACO 在符合质量标准的情况下分享任何成本节约，为其三大主要目标中的两个奠定了基础。然而，可问责医疗的公共卫生目标——可以说是这三个目标中最重要的——似乎被抛在了后面。为了更好地实现公共卫生目标，我们提出了一种在 ACO 内部进行质量报告的新方法：引入一个“扩展分母”，如果患者曾在某个医疗系统内就诊，就将其归为该医疗系统。扩展分母将确保 ACO 不仅要对已经接受初级保健的患者负责，还要对医疗服务零散的患者以及未得到充分治疗的高危社区成员负责。最终，医疗保险以及可能还有医疗补助的支付改革必须支持这种新的质量衡量方法，使其产生持久影响。
