Herrel Lindsey A, Ayanian John Z, Hawken Scott R, Miller David C
Dow Division of Health Services Research, University of Michigan, Ann Arbor, Michigan, USA.
Department of Urology, University of Michigan, Ann Arbor, Michigan, USA.
BMC Health Serv Res. 2017 Feb 15;17(1):139. doi: 10.1186/s12913-017-2092-8.
Although Accountable Care Organizations (ACOs) are defined by the provision of primary care services, the relationship between the intensity of primary care and population-level utilization and costs of health care services has not been examined during early implementation of Medicare Shared Savings Program (MSSP) ACOs. Our objective was to evaluate the association between primary care focus and healthcare utilization and spending in the first performance period of the Medicare Shared Savings Program (MSSP) Accountable Care Organizations (ACOs).
In this retrospective cohort study, we divided the 220 MSSP ACOs into quartiles of primary care focus based on the percentage of all ambulatory evaluation and management services delivered by a PCP (internist, family physician, or geriatrician). Using multivariable regression, we evaluated rates of utilization and spending during the initial performance period, adjusting for the percentage of non-white patients, region, number of months enrolled in the MSSP, number of beneficiary person years, percentage of dual eligible beneficiaries and percentage of beneficiaries over the age of 74.
The proportion of ambulatory evaluation and management services delivered by a PCP ranged from <38% (lowest quartile, ACOs with least PCP focus) to >46% (highest quartile, ACOs with greatest PCP focus). ACOs in the highest quartile of PCP focus had higher adjusted rates of utilization of acute care hospital admissions (328 per 1000 person years vs 292 per 1000 person years, p = 0.01) and emergency department visits (756 vs 680 per 1000 person years, p = 0.02) compared with ACOs in the lowest quartile of PCP focus. ACOs in the highest quartile of PCP focus achieved no greater savings per beneficiary relative to their spending benchmarks ($142 above benchmark vs $87 below benchmark, p = 0.13).
Primary care focus was not associated with increased savings or lower utilization of healthcare during the initial implementation of MSSP ACOs.
尽管 accountable care organizations（ACO）是通过提供初级保健服务来定义的，但在医疗保险共享节约计划（MSSP）ACO 的早期实施阶段，初级保健强度与人群层面的医疗服务利用率和成本之间的关系尚未得到研究。我们的目标是评估在医疗保险共享节约计划（MSSP） accountable care organizations（ACO）的首个绩效期内，初级保健重点与医疗服务利用和支出之间的关联。
在这项回顾性队列研究中，我们根据初级保健医生（内科医生、家庭医生或老年病医生）提供的所有门诊评估和管理服务的百分比，将 220 个 MSSP ACO 分为初级保健重点的四分位数。使用多变量回归，我们评估了初始绩效期内的利用率和支出率，并对非白人患者的百分比、地区、参加 MSSP 的月数、受益人人年数、双重资格受益人的百分比以及 74 岁以上受益人的百分比进行了调整。
初级保健医生提供的门诊评估和管理服务的比例范围从<38%（最低四分位数，初级保健重点最少的 ACO）到>46%（最高四分位数，初级保健重点最大的 ACO）。与初级保健重点最低四分位数的 ACO 相比，初级保健重点最高四分位数的 ACO 的急性护理医院入院调整利用率更高（每 1000 人年 328 次 vs 每 1000 人年 292 次，p = 0.01），急诊科就诊率更高（每 1000 人年 756 次 vs 680 次，p = 0.02）。初级保健重点最高四分位数的 ACO 相对于其支出基准，每位受益人的节省并不更多（比基准高 142 美元 vs 比基准低 87 美元，p = 0.13）。
在 MSSP ACO 的初始实施阶段，初级保健重点与增加节省或降低医疗服务利用率无关。
