Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts2Department of Medicine, Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
JAMA Intern Med. 2013 Aug 12;173(15):1447-56. doi: 10.1001/jamainternmed.2013.6886.
The Medicare accountable care organization (ACO) programs rely on delivery system integration and health care provider risk sharing to lower spending while improving quality of care.
To compare spending and quality between larger and smaller provider groups and examine how size-related differences vary by 2 factors considered central to ACO performance: group primary care orientation and financial risk sharing by health care providers.
Using 2009 Medicare claims and linked American Medical Association Group Practice data, we assigned 4.29 million beneficiaries to health care provider groups based on primary care use. We categorized group size according to eligibility thresholds for the Shared Savings (≥5000 assigned beneficiaries) and Pioneer (≥15,000) ACO programs and distinguished hospital-based from independent groups. We assessed the primary care orientation of larger groups' specialty mix and used health maintenance organization market penetration and data from the Community Tracking Study to measure the extent of financial risk accepted by different types of provider groups in different areas for managed care patients. We estimated linear regression models comparing spending and quality between larger and smaller health care provider groups, allowing size-related differences to vary by measures of group primary care orientation and risk sharing. Spending and quality measures included total medical spending, spending by type of service, 5 process measures of quality, and 30-day readmissions, all adjusted for sociodemographic and clinical characteristics.
Compared with smaller groups, larger hospital-based groups had higher total per-beneficiary spending in 2009 (mean difference, +$849), higher 30-day readmission rates (+1.3 percentage points), and similar performance on 4 of 5 process measures of quality. In contrast, larger independent physician groups performed better than smaller groups on all process measures and exhibited significantly lower per-beneficiary spending in counties where risk sharing by these groups was more common (-$426). Among all groups sufficiently large to participate in ACO programs, a strong primary care orientation was associated with lower spending, fewer readmissions, and better quality of diabetes care.
Spending was lower and quality of care better for Medicare beneficiaries served by larger independent physician groups with strong primary care orientations in environments where health care providers accepted greater risk.
医疗保险责任制医疗组织（ACO）计划依靠医疗体系整合和医疗服务提供者的风险分担来降低支出，同时提高医疗质量。
比较较大和较小提供者群体之间的支出和质量，并研究与 ACO 绩效相关的两个因素（群体的初级保健定位和医疗服务提供者的财务风险分担）如何影响规模相关的差异。
使用 2009 年医疗保险索赔和关联的美国医学协会团体实践数据，我们根据初级保健的使用情况，将 429 万受益人与医疗服务提供者群体相匹配。我们根据共享储蓄（≥5000 名指定受益者）和先驱（≥15000 名）ACO 计划的资格标准，以及基于医院的团体与独立团体，对团体规模进行了分类。我们评估了较大团体专业组合的初级保健定位，并使用健康维护组织市场渗透率和社区跟踪研究的数据，衡量不同类型的提供者群体在不同地区为管理式医疗患者承担的财务风险程度。我们使用线性回归模型，比较了较大和较小医疗服务提供者群体之间的支出和质量，允许通过群体初级保健定位和风险分担的措施来改变与规模相关的差异。支出和质量的衡量标准包括总医疗支出、按服务类型划分的支出、5 项质量过程衡量标准和 30 天再入院率，所有这些都根据社会人口统计学和临床特征进行了调整。
与较小的团体相比，较大的基于医院的团体在 2009 年的每位受益人的总支出更高（平均差异为+849 美元），30 天再入院率更高（增加 1.3 个百分点），在 5 项质量过程衡量标准中的 4 项表现相似。相比之下，较大的独立医生团体在所有过程衡量标准上的表现都优于较小的团体，并且在这些团体的风险分担更为常见的县，每位受益人的支出显著降低（-426 美元）。在所有足够大以参与 ACO 计划的团体中，较强的初级保健定位与较低的支出、较低的再入院率和更好的糖尿病护理质量相关。
在接受具有较强初级保健定位的较大独立医生团体的医疗保险受益人的环境中，风险分担程度更高，医疗支出更低，医疗质量更好。
