Department of Health Policy and Promotion, University of Massachusetts Amherst, Amherst.
JAMA Netw Open. 2019 Jul 3;2(7):e196796. doi: 10.1001/jamanetworkopen.2019.6796.
Accountable care organizations (ACOs) aim to control health expenditures while improving quality of care. Primary care has been emphasized as a means to reduce spending, but little is known about the implications of using specialists for achieving this ACO objective.
To examine the association between ACO-beneficiary office visits conducted by specialists and the cost and utilization outcomes of those visits.
DESIGN, SETTING, AND PARTICIPANTS: This cross-sectional study obtained data on 620 distinct ACOs from the Centers for Medicare & Medicaid Services Shared Savings Program Accountable Care Organizations Public-Use Files from April 1, 2012, to September 30, 2017. Generalized estimating equation models were used for analysis of ACOs, adjusting for ACO-beneficiary health status, Medicare enrollment groups, ACO size, and proportion of participating specialists.
Specialist encounter proportion, the percentage of office visits provided by a specialist, was categorized into 7 discrete groups: less than 35%, 35% to less than 40%, 40% to less than 45% (reference group), 45% to less than 50%, 50% to less than 55%, 55% to less than 60%, and 60% or greater.
The primary outcome was total expenditures (given in US dollars) per assigned beneficiary person-year. The secondary outcomes were total numbers of emergency department visits, hospital discharges, skilled nursing facility discharges, and magnetic resonance imaging orders.
In total, the data set included 1836 ACO-year (number of participation years per ACO) observations for 620 distinct ACOs. Those ACOs with a specialist encounter proportion of 40% to less than 45% had $1129 (95% CI, $445-$1814) lower per-beneficiary person-year spending than did ACOs in the lowest specialist encounter proportion group and had $752 (95% CI, $115-$1389) lower per-beneficiary person-year spending compared with ACOs in the highest specialist encounter proportion group. Monotonic decreases in emergency department visits, hospital discharges, and skilled nursing facility discharges were observed with increasing specialist encounter proportion. Conversely, monotonic increases in magnetic resonance imaging volume discharges were observed with increasing specialist encounter proportion.
These findings suggest that an ACO's ability to reduce spending may require sufficient involvement in care processes from specialists, who seem to complement the intrinsic primary care approach in ACOs.
责任医疗组织（ACO）旨在控制医疗支出，同时提高医疗质量。已经强调初级保健是减少支出的一种手段，但对于利用专家来实现这一 ACO 目标的影响知之甚少。
研究 ACO 中专家提供的服务与这些服务的成本和利用结果之间的关系。
设计、设置和参与者：本横断面研究从 2012 年 4 月 1 日至 2017 年 9 月 30 日，从医疗保险和医疗补助服务共享储蓄计划责任医疗组织公共使用文件中获取了 620 个不同的 ACO 数据。使用广义估计方程模型对 ACO 进行分析，调整了 ACO-受益人的健康状况、医疗保险登记组、ACO 规模和参与专家的比例。
专家就诊比例，即专家提供的就诊百分比，分为 7 个离散组：小于 35%、35%至小于 40%、40%至小于 45%（参考组）、45%至小于 50%、50%至小于 55%、55%至小于 60%和 60%或更高。
主要结果是每个指定受益人人年的总支出（以美元计）。次要结果是急诊就诊次数、住院出院人数、熟练护理设施出院人数和磁共振成像订单数。
在总共 1836 个 ACO 年（每个 ACO 的参与年数）观察中，包括 620 个不同 ACO 的数据。与最低专家就诊比例组相比，专家就诊比例为 40%至 45%的 ACO 每个受益人人年的支出减少了 1129 美元（95%CI，445 美元至 1814 美元），与最高专家就诊比例组相比，每个受益人人年的支出减少了 752 美元（95%CI，115 美元至 1389 美元）。随着专家就诊比例的增加，急诊就诊次数、住院出院人数和熟练护理设施出院人数呈单调减少趋势。相反，随着专家就诊比例的增加，磁共振成像量的出院人数呈单调增加趋势。
这些发现表明，ACO 降低支出的能力可能需要专家充分参与护理过程，专家似乎补充了 ACO 中固有的初级保健方法。
