From the Department of Health Care Policy, Harvard Medical School (J.M.M., B.E.L., M.E.C., A.M.Z.), the Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School (J.M.M.), and the Division of General Internal Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center (B.E.L.) - all in Boston.
N Engl J Med. 2014 Oct 30;371(18):1715-24. doi: 10.1056/NEJMsa1406552.
Incentives for accountable care organizations (ACOs) to limit health care use and improve quality may enhance or hurt patients' experiences with care.
Using Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey data covering 3 years before and 1 year after the start of Medicare ACO contracts in 2012 as well as linked Medicare claims, we compared patients' experiences in a group of 32,334 fee-for-service beneficiaries attributed to ACOs (ACO group) with those in a group of 251,593 beneficiaries attributed to other providers (control group), before and after the start of ACO contracts. We used linear regression and a difference-in-differences analysis to estimate changes in patients' experiences in the ACO group that differed from concurrent changes in the control group, with adjustment for the sociodemographic and clinical characteristics of the patients.
After ACO contracts began, patients' reports of timely access to care and their primary physicians' being informed about specialty care differentially improved in the ACO group, as compared with the control group (P=0.01 and P=0.006, respectively), whereas patients' ratings of physicians, interactions with physicians, and overall care did not differentially change. Among patients with multiple chronic conditions and high predicted Medicare spending, overall ratings of care differentially improved in the ACO group as compared with the control group (P=0.02). Differential improvements in timely access to care and overall ratings were equivalent to moving from average performance among ACOs to the 86th to 98th percentile (timely access to care) and to the 82nd to 96th percentile (overall ratings) and were robust to adjustment for group differences in trends during the preintervention period.
In the first year, ACO contracts were associated with meaningful improvements in some measures of patients' experience and with unchanged performance in others. (Funded by the National Institute on Aging and others.).
为了限制医疗保健的使用和提高医疗质量，对问责制医疗保健组织（ACO）的激励措施可能会增强或损害患者对护理的体验。
利用覆盖 2012 年医疗保险 ACO 合同开始前 3 年和开始后 1 年的医疗保健提供者和系统消费者评估（CAHPS）调查数据以及相关的医疗保险索赔，我们将归因于 ACO 的 32334 名按服务收费受益人的患者经历与归因于其他提供者的 251593 名受益人的患者经历进行了比较（对照组），比较了 ACO 合同开始前后的患者经历。我们使用线性回归和差异中的差异分析来估计 ACO 组患者经历的变化，这些变化与对照组的同期变化不同，并对患者的社会人口统计学和临床特征进行了调整。
在 ACO 合同开始后，与对照组相比，患者报告的及时获得护理的机会和他们的初级医生了解专科护理的机会都有所不同，在 ACO 组得到了改善（P=0.01 和 P=0.006），而医生的评分、与医生的互动以及整体护理并没有发生不同的变化。在患有多种慢性疾病和高预测性医疗保险支出的患者中，与对照组相比，ACO 组的整体护理评分有所不同（P=0.02）。及时获得护理的机会和整体评分的差异改善相当于从 ACO 的平均表现提高到第 86 至 98 百分位（及时获得护理）和第 82 至 96 百分位（整体评分），并且在调整了干预前期间的组间趋势差异后仍然稳健。
在第一年，ACO 合同与患者体验的一些衡量标准的显著改善有关，而其他衡量标准的表现则保持不变。（由美国国家老龄化研究所和其他机构资助）。
