Sinha Shashank S, Moloci Nicholas M, Ryan Andrew M, Markovitz Adam A, Colla Carrie H, Lewis Valerie A, Hollenbeck Brent K, Nallamothu Brahmajee K, Hollingsworth John M
Division of Cardiovascular Medicine, Department of Internal Medicine (S.S.S., B.K.N.).
Institute for Healthcare Policy and Innovation (S.S.S., N.M.M., A.M.R., A.A.M., B.K.H., B.K.N.), University of Michigan Medical School, Ann Arbor.
Circ Cardiovasc Qual Outcomes. 2018 Aug;11(8):e004495. doi: 10.1161/CIRCOUTCOMES.117.004495.
Initial evaluations of the Pioneer and Shared Savings Programs have shown modest savings associated with care receipt in a Medicare accountable care organization (ACO). Whether these savings are affected by disease chronicity and the mechanisms through which they occur are unclear. In this context, we examined the association between Medicare ACO implementation and episode spending for 2 different cardiovascular conditions.
We analyzed a 20% sample of national Medicare data, identifying fee-for-service beneficiaries aged ≥65 years admitted for acute myocardial infarction (AMI) or congestive heart failure (CHF) between January 2010 and October 2014. We distinguished admissions to hospitals participating in a Medicare ACO from those to hospitals that were not. We calculated 365-day, price-standardized episode spending made on behalf of these beneficiaries, differentiating between early (index admission to 90 days postdischarge) and late payments (91-365 days postdischarge). Using an interrupted time series design, we fit longitudinal multivariable models to estimate the association between hospital ACO participation and episode spending. Our study included 153 476 beneficiaries admitted for AMI to 401 ACO participating hospitals and 2597 nonparticipating hospitals and 260 420 beneficiaries admitted for CHF to 412 ACO participating hospitals and 2796 nonparticipating hospitals. On multivariable analysis, admission to an ACO participating hospital was not associated with changes in early episode spending (AMI, $95 per beneficiary; 95% CI, -$481 to $671; CHF, $158; 95% CI, -$290 to $605). However, it was associated with significant reductions in late episode spending for both cohorts (AMI, -$680; 95% CI, -$1348 to -$11; CHF, -$889; 95% CI, -$1465 to -$313).
For beneficiaries with AMI or CHF, admission to ACO participating hospitals was not associated with changes in early episode spending, but it was associated with significant savings during the late episode. ACO effects on late episode spending may complement other value-based payment reforms that target the early episode.
对先锋和共享储蓄计划的初步评估显示，在医疗保险责任医疗组织（ACO）中，与接受治疗相关的储蓄较为适度。这些储蓄是否受疾病慢性程度影响以及其产生的机制尚不清楚。在此背景下，我们研究了医疗保险ACO实施与两种不同心血管疾病的发作期支出之间的关联。
我们分析了全国医疗保险数据的20%样本，确定了2010年1月至2014年10月期间因急性心肌梗死（AMI）或充血性心力衰竭（CHF）入院的65岁及以上按服务收费的受益人。我们区分了入住参与医疗保险ACO的医院的患者和未参与的医院的患者。我们计算了代表这些受益人进行的365天价格标准化发作期支出，区分了早期（索引入院至出院后90天）和后期支付（出院后91 - 365天）。使用中断时间序列设计，我们拟合纵向多变量模型来估计医院ACO参与与发作期支出之间的关联。我们的研究包括153476名因AMI入住401家参与ACO的医院和2597家非参与医院的受益人，以及260420名因CHF入住412家参与ACO的医院和2796家非参与医院的受益人。在多变量分析中，入住参与ACO的医院与早期发作期支出的变化无关（AMI，每位受益人95美元；95%置信区间，-481美元至671美元；CHF，158美元；95%置信区间，-290美元至605美元）。然而，它与两个队列后期发作期支出的显著减少相关（AMI，-680美元；95%置信区间，-1348美元至-11美元；CHF，-889美元；95%置信区间，-1465美元至-313美元）。
对于患有AMI或CHF的受益人，入住参与ACO的医院与早期发作期支出的变化无关，但与后期发作期的显著储蓄相关。ACO对后期发作期支出的影响可能补充了针对早期发作期的其他基于价值的支付改革。
