全球支付实施 4 年后医疗支出和质量的变化
Changes in health care spending and quality 4 years into global payment.
机构信息
From the Department of Medicine, Massachusetts General Hospital (Z.S.), Department of Health Care Policy, Harvard Medical School (Z.S., S.R., B.E.L., M.E.C.), Blue Cross Blue Shield of Massachusetts (D.G.S., M.P.D.), the Department of Medicine, Tufts University School of Medicine (D.G.S.), and the Department of Medicine, Beth Israel Deaconess Medical Center (B.E.L.) - all in Boston; and the National Bureau of Economic Research, Cambridge, MA (Z.S., M.E.C.).
出版信息
N Engl J Med. 2014 Oct 30;371(18):1704-14. doi: 10.1056/NEJMsa1404026.
BACKGROUND
Spending and quality under global budgets remain unknown beyond 2 years. We evaluated spending and quality measures during the first 4 years of the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC).
METHODS
We compared spending and quality among enrollees whose physician organizations entered the AQC from 2009 through 2012 with those among persons in control states. We studied spending changes according to year, category of service, site of care, experience managing risk contracts, and price versus utilization. We evaluated process and outcome quality.
RESULTS
In the 2009 AQC cohort, medical spending on claims grew an average of $62.21 per enrollee per quarter less than it did in the control cohort over the 4-year period (P<0.001). This amount is equivalent to a 6.8% savings when calculated as a proportion of the average post-AQC spending level in the 2009 AQC cohort. Analogously, the 2010, 2011, and 2012 cohorts had average savings of 8.8% (P<0.001), 9.1% (P<0.001), and 5.8% (P=0.04), respectively, by the end of 2012. Claims savings were concentrated in the outpatient-facility setting and in procedures, imaging, and tests, explained by both reduced prices and reduced utilization. Claims savings were exceeded by incentive payments to providers during the period from 2009 through 2011 but exceeded incentive payments in 2012, generating net savings. Improvements in quality among AQC cohorts generally exceeded those seen elsewhere in New England and nationally.
CONCLUSIONS
As compared with similar populations in other states, Massachusetts AQC enrollees had lower spending growth and generally greater quality improvements after 4 years. Although other factors in Massachusetts may have contributed, particularly in the later part of the study period, global budget contracts with quality incentives may encourage changes in practice patterns that help reduce spending and improve quality. (Funded by the Commonwealth Fund and others.).
背景
全球预算下的支出和质量在两年后仍不得而知。我们评估了马萨诸塞州蓝十字蓝盾替代质量合同（AQC）实施的前 4 年期间的支出和质量措施。
方法
我们比较了 2009 年至 2012 年期间加入 AQC 的医生组织的参保人与控制州参保人的支出和质量。我们根据年份、服务类别、护理地点、管理风险合同的经验以及价格与利用率，研究了支出变化。我们评估了过程和结果质量。
结果
在 2009 年 AQC 队列中，与对照组相比，在四年期间，每位参保人每季度的索赔医疗支出平均减少了 62.21 美元（P<0.001）。当按 2009 年 AQC 队列中 AQC 后平均支出水平的比例计算时，这相当于节省了 6.8%。类似地，2010 年、2011 年和 2012 年队列在 2012 年底分别平均节省了 8.8%（P<0.001）、9.1%（P<0.001）和 5.8%（P=0.04）。索赔节省主要集中在门诊设施和程序、成像和检查，这归因于价格降低和利用率降低。在 2009 年至 2011 年期间，向提供者支付的激励性付款超过了索赔节省，但在 2012 年超过了激励性付款，产生了净节省。与新英格兰和全国其他地区相比，AQC 队列的质量一般都有所提高。
结论
与其他州的类似人群相比，马萨诸塞州 AQC 参保人在四年后支出增长较低，质量普遍提高。尽管马萨诸塞州的其他因素可能也有贡献，特别是在研究后期，但具有质量激励的全球预算合同可能会鼓励实践模式的改变，有助于降低支出和提高质量。（由 Commonwealth Fund 及其他机构资助）。
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