McWilliams J Michael, Gilstrap Lauren G, Stevenson David G, Chernew Michael E, Huskamp Haiden A, Grabowski David C
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts2Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts3Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
JAMA Intern Med. 2017 Apr 1;177(4):518-526. doi: 10.1001/jamainternmed.2016.9115.
Postacute care is thought to be a major source of wasteful spending. The extent to which accountable care organizations (ACOs) can limit postacute care spending has implications for the importance and design of other payment models that include postacute care.
To assess changes in postacute care spending and use of postacute care associated with provider participation as ACOs in the Medicare Shared Savings Program (MSSP) and the pathways by which they occurred.
DESIGN, SETTING, AND PARTICIPANTS: With the use of fee-for-service Medicare claims from a random 20% sample of beneficiaries with 25 544 650 patient-years, 8 395 426 hospital admissions, and 1 595 352 stays in skilled nursing facilities (SNFs) from January 1, 2009, to December 31, 2014, difference-in-difference comparisons of beneficiaries served by ACOs with beneficiaries served by local non-ACO health care professionals (control group) were performed before vs after entry into the MSSP. Differential changes were estimated separately for cohorts of ACOs entering the MSSP in 2012, 2013, and 2014.
Patient attribution to an ACO in the MSSP.
Postacute spending, discharge to a facility, length of SNF stays, readmissions, use of highly rated SNFs, and mortality, adjusted for patient characteristics.
For the 2012 cohort of 114 ACOs, participation in the MSSP was associated with an overall reduction in postacute spending (differential change in 2014 for ACOs vs control group, -$106 per beneficiary [95% CI, -$176 to -$35], or -9.0% of the precontract unadjusted mean of $1172; P = .003) that was driven by differential reductions in acute inpatient care, discharges to facilities rather than home (-0.6 percentage points [95% CI, -1.1 to 0.0], or -2.7% of the unadjusted precontract mean of 22.6%; P = .03), and length of SNF stays (-0.60 days per stay [95% CI, -0.99 to -0.22], or -2.2% of the precontract unadjusted mean of 27.07 days; P = .002). Reductions in use of SNFs and length of stay were largely due to within-hospital or within-SNF changes in care specifically for ACO patients. Participation in the MSSP was associated with smaller significant reductions in SNF spending in 2014 for the 2013 ACO cohort (-$27 per beneficiary [95% CI, -$49 to -$6], or -3.3% of the precontract unadjusted mean of $813; P = .01) but not in the 2013 or 2014 cohort's first year of participation (-$13 per beneficiary [95% CI, -$33 to $6]; P = .19; and $4 per beneficiary [95% CI, -$15 to $24]; P = .66). Estimates were similar for ACOs with and without financial ties to hospitals. Participation in the MSSP was not associated with significant changes in 30-day readmissions, use of highly rated SNFs, or mortality.
Participation in the MSSP has been associated with significant reductions in postacute spending without ostensible deterioration in quality of care. Spending reductions were more consistent with clinicians working within hospitals and SNFs to influence care for ACO patients than with hospital-wide initiatives by ACOs or use of preferred SNFs.
急性后期护理被认为是浪费性支出的一个主要来源。 accountable care organizations（ACO）能够在多大程度上限制急性后期护理支出，对于包括急性后期护理在内的其他支付模式的重要性和设计具有影响。
评估与参与医疗保险共享节约计划（MSSP）中的ACO相关的急性后期护理支出和急性后期护理使用情况的变化，以及这些变化发生的途径。
设计、设置和参与者：利用2009年1月1日至2014年12月31日期间20%随机抽取的受益人的按服务收费医疗保险索赔数据，这些受益人有25544650患者年、8395426次住院以及1595352次在专业护理机构（SNF）的停留，对ACO服务的受益人与当地非ACO医疗保健专业人员服务的受益人（对照组）在进入MSSP之前和之后进行了差分比较。分别对2012年、2013年和2014年进入MSSP的ACO队列的差异变化进行了估计。
MSSP中患者被分配到ACO。
急性后期支出、出院到机构、SNF停留时间、再入院、使用高评级SNF以及死亡率，并对患者特征进行了调整。
对于2012年的114个ACO队列，参与MSSP与急性后期支出的总体减少相关（2014年ACO与对照组的差异变化为，每位受益人减少106美元[95%CI，-176至-35美元]，即预合同未调整均值1172美元的-9.0%；P = 0.003），这是由急性住院护理的差异减少、出院到机构而非家中（-0.6个百分点[95%CI，-1.1至0.0]，即未调整预合同均值22.6%的-2.7%；P = 0.03）以及SNF停留时间（每次停留减少0.60天[95%CI，-0.99至-0.22]，即预合同未调整均值27.
