医院参与责任医疗组织后康复护理使用的变化是否会外溢到所有 Medicare 受益人？
Do Changes in Post-acute Care Use at Hospitals Participating in an Accountable Care Organization Spillover to All Medicare Beneficiaries?
机构信息
Corporal Michael J. Cresencz VA Medical Center, Philadelphia, PA, USA.
Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
出版信息
J Gen Intern Med. 2018 Jun;33(6):831-838. doi: 10.1007/s11606-018-4368-z. Epub 2018 Mar 8.
BACKGROUND
While early evidence suggests that Medicare accountable care organizations (ACOs) may reduce post-acute care (PAC) utilization for attributed beneficiaries, whether these effects spill over to all beneficiaries admitted to hospitals participating in ACOs stray is unknown.
OBJECTIVE
The objective of this study was to evaluate whether changes in PAC use and Medicare spending spill over to all beneficiaries admitted to hospitals participating in the Medicare Shared Savings Program (MSSP).
DESIGN
Observational study using a difference-in-differences design comparing changes in PAC utilization and spending among beneficiaries admitted to ACO-participating hospitals before and after the start of the ACO contracts, compared to those admitted to non-ACO hospitals.
SETTING
A total of 233 hospitals participate in MSSP ACOs and 3103 non-ACO hospitals.
PARTICIPANTS
A national sample of 11,683,573 Medicare beneficiaries experiencing 26,503,086 hospital admissions from 2010 to 2013.
EXPOSURE
Admission to a hospital participating in an MSSP ACO.
MAIN MEASURES
The probability of discharge and Medicare payments to inpatient rehabilitation facilities (IRF), skilled nursing facilities (SNF), and home health agencies (HHA).
KEY RESULTS
For beneficiaries admitted to hospitals that joined an ACO, the likelihood of being discharged to PAC did not change after the hospital joined the ACO compared with non-ACO hospitals over the same period (differential change in probability of discharge to any PAC was 0.000 (P = 0.89), SNF was 0.000 (P = 0.73), IRF was 0.000 (P = 0.96), and HHA was 0.001 (P = 0.57)). Payments reduced significantly for PAC overall (- $130.41, P = 0.03), but not for any individual PAC type alone. These results were consistent in samples that were conditional on discharge to any PAC, across conditions with high PAC use nationally, and among ACO-participating hospitals that also had a PAC participant.
CONCLUSIONS
Hospital participation in an ACO did not result in spillovers in PAC utilization or payments to all beneficiaries, even when considering high PAC-use conditions and ACO hospitals that also have an ACO-participating PAC.
背景
虽然早期证据表明，医疗保险责任制医疗组织（ACO）可能会减少归因受益人的后期康复护理（PAC）的使用，但这些影响是否会蔓延到所有参与 ACO 的医院收治的受益人的身上还不得而知。
目的
本研究的目的是评估 PAC 使用和医疗保险支出的变化是否会蔓延到所有参与医疗保险共享储蓄计划（MSSP）的医院收治的受益人中。
设计
使用差异中的差异设计的观察性研究，比较在 ACO 合同开始前后，参与 ACO 的医院收治的受益人与非 ACO 医院收治的受益人的 PAC 使用和支出变化，以评估 ACO 参与对所有受益人的影响。
设置
共有 233 家医院参与 MSSP ACO，3103 家非 ACO 医院。
参与者
2010 年至 2013 年期间，11683573 名经历 26503086 次住院的 Medicare 受益人的全国性样本。
暴露
入住参与 MSSP ACO 的医院。
主要观察指标
住院康复设施（IRF）、熟练护理设施（SNF）和家庭健康机构（HHA）的出院概率和医疗保险支付情况。
主要结果
对于入住 ACO 医院的受益人的 PAC 出院可能性在医院加入 ACO 后与同期非 ACO 医院相比并没有改变（出院到任何 PAC 的概率差异变化为 0.000（P=0.89），SNF 为 0.000（P=0.73），IRF 为 0.000（P=0.96），HHA 为 0.001（P=0.57））。PAC 的整体支付显著减少（-130.41 美元，P=0.03），但任何单一 PAC 类型的支付都没有显著减少。这些结果在所有 PAC 出院的样本中、在全国 PAC 使用量较高的条件下以及在也有 PAC 参与的 ACO 参与医院中都是一致的。
结论
即使考虑到 PAC 使用量高的情况和也有 ACO 参与的 PAC 的 ACO 参与医院，医院参与 ACO 并没有导致 PAC 使用或向所有受益人的支付溢出。
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