Centers for Medicare & Medicaid Services, Baltimore, Maryland2Center for Medicare and Medicaid Innovation, Baltimore, Maryland.
JAMA. 2015 Jun 2;313(21):2152-61. doi: 10.1001/jama.2015.4930.
The Pioneer Accountable Care Organization (ACO) Model aims to drive health care organizations to reduce expenditures while improving quality for fee-for-service (FFS) Medicare beneficiaries.
To determine whether FFS beneficiaries aligned with Pioneer ACOs had smaller increases in spending and utilization than other FFS beneficiaries while retaining similar levels of care satisfaction in the first 2 years of the Pioneer ACO Model.
DESIGN, SETTING, AND PARTICIPANTS: Participants were FFS Medicare beneficiaries aligned with 32 ACOs (n = 675,712 in 2012; n = 806,258 in 2013) and a comparison group of alignment-eligible beneficiaries in the same markets (n = 13,203,694 in 2012; n = 12,134,154 in 2013). Analyses comprised difference-in-differences multivariable regression with Oaxaca-Blinder reweighting to model expenditure and utilization outcomes over a 2-year performance period (2012-2013) and 2-year baseline period (2010-2011) as well as adjusted analyses of Consumer Assessment of Healthcare Providers & Systems (CAHPS) survey responses among random samples of beneficiaries in Pioneer ACOs (n = 13,097), FFS (n = 116,255), or Medicare Advantage (n = 203,736) for 2012 care.
Beneficiary alignment with a Pioneer ACO in 2012 or 2013.
Medicare spending, utilization, and CAHPS domain scores.
Total spending for beneficiaries aligned with Pioneer ACOs in 2012 or 2013 increased from baseline to a lesser degree relative to comparison populations. Differential changes in spending were approximately -$35.62 (95% CI, -$40.12 to -$31.12) per-beneficiary-per-month (PBPM) in 2012 and -$11.18 (95% CI, -$15.84 to -$6.51) PBPM in 2013, which amounted to aggregate reductions in increases of approximately -$280 (95% CI, -$315 to -$244) million in 2012 and -$105 (95% CI, -$148 to -$61) million in 2013. Inpatient spending showed the largest differential change of any spending category (-$14.40 [95% CI, -$17.31 to -$11.49] PBPM in 2012; -$6.46 [95% CI, -$9.26 to -$3.66] PBPM in 2013). Changes in utilization of physician services, emergency department, and postacute care followed a similar pattern. Compared with other Medicare beneficiaries, ACO-aligned beneficiaries reported higher mean scores for timely care (77.2 [ACO] vs 71.2 [FFS] vs 72.7 [MA]) and for clinician communication (91.9 [ACO] vs 88.3 [FFS] vs 88.7 [MA]).
In the first 2 years of the Pioneer ACO Model, beneficiaries aligned with Pioneer ACOs, as compared with general Medicare FFS beneficiaries, exhibited smaller increases in total Medicare expenditures and differential reductions in utilization of different health services, with little difference in patient experience.
重要性：先锋责任医疗组织（ACO）模式旨在推动医疗机构在为医疗保险（Medicare）的按服务收费（FFS）受益人群提供服务的同时减少开支，提高质量。
目的：确定在先锋 ACO 模式的前 2 年中，与先锋 ACO 一致的 FFS 受益人群与其他 FFS 受益人群相比，在保持类似的护理满意度的同时，支出和利用的增长幅度是否更小。
设计、地点和参与者：参与者为与 32 个 ACO 一致的 FFS Medicare 受益人群（2012 年为 675712 人，2013 年为 806258 人）和同一市场中符合条件的对照受益人群（2012 年为 13203694 人，2013 年为 12134154 人）。分析包括使用 Oaxaca-Blinder 重新加权的差异中的差异多变量回归，以在 2 年的绩效期（2012-2013 年）和 2 年的基线期（2010-2011 年）内对支出和利用结果进行建模，以及对先锋 ACO（n=13097）、FFS（n=116255）或 Medicare Advantage（n=203736）的随机受益人群样本进行调整后的消费者医疗保健提供者和系统评估（CAHPS）调查结果分析，2012 年的护理。
暴露：2012 年或 2013 年与先锋 ACO 一致的受益人群。
主要结果和测量：医疗保险支出、利用和 CAHPS 域分数。
结果：2012 年或 2013 年与先锋 ACO 一致的受益人群的总支出相对于对照组人群，从基线到较小的程度增加。支出的差异变化约为每月每受益人群（per-beneficiary-per-month，PBPM）-35.62 美元（95%CI，-40.12 美元至-31.12 美元），2013 年为-11.18 美元（95%CI，-15.84 美元至-6.51 美元），相当于 2012 年约减少 2.80 亿美元（95%CI，-3.15 亿美元至-2.44 亿美元），2013 年约减少 1.05 亿美元（95%CI，-1.48 亿美元至-0.61 亿美元）。住院支出是所有支出类别中差异变化最大的，-14.40 美元（95%CI，-17.31 美元至-11.49 美元）PBPM，2013 年为-6.46 美元（95%CI，-9.26 美元至-3.66 美元）PBPM。医生服务、急诊和后期医疗利用的变化遵循类似的模式。与其他 Medicare 受益人群相比，与 ACO 一致的受益人群报告了更高的及时护理（77.2[ACO]比 71.2[FFS]比 72.7[MA]）和临床医生沟通（91.9[ACO]比 88.3[FFS]比 88.7[MA]）的平均分数。
结论和相关性：在先锋 ACO 模式的前 2 年中，与普通 Medicare FFS 受益人群相比，与先锋 ACO 一致的受益人群的医疗保险总支出增长幅度较小，不同医疗服务的利用减少，患者体验差异不大。
