Harvard Interfaculty Initiative in Health Policy, 14 Story St, Cambridge, MA 02138. Email:
Am J Manag Care. 2020 Apr;26(4):170-175. doi: 10.37765/ajmc.2020.42834.
Understanding variation in spending across organizations, rather than across geographic areas, is important because care is delivered by organizations and interventions increasingly focus on organizations. Accountable care organizations (ACOs) are particularly important to study given their incentives to reduce spending. Analyzing spending differences across ACOs may help identify cost savings opportunities.
Cross-sectional analysis of Medicare claims.
We stratified ACOs into quartiles based on the deviation between each ACO's risk-adjusted spending and average risk-adjusted fee-for-service spending in the same market (hospital referral region). We compared spending between top- and bottom-quartile ACOs on each of 7 major service categories and 10 clinical condition groups to identify areas of potential savings. We simulated spending reductions if ACOs with high adjusted spending reduced spending to the levels of lower-spending ACOs.
In 2016, geographically adjusted and risk-adjusted total per-beneficiary spending for the highest-spending quartile of ACOs was 14% higher than for ACOs in the lowest quartile. Variation between high- and low-spending ACOs was greatest, at 27%, in the use of skilled nursing facilities-a service category in which ACOs have reduced spending by the greatest percentage. Inpatient care was the largest driver of absolute dollar differences in spending, however, accounting for 37% of the total spread. If spending in ACOs above median adjusted spending were brought down to the median, savings would be 3% to 4%.
By extending the variations literature to focus on ACOs, we illustrated that meaningful further savings opportunities exist both within and across markets.
了解组织之间而非地理区域之间的支出差异很重要，因为医疗服务是由组织提供的，干预措施越来越侧重于组织。鉴于责任医疗组织（ACO）有降低支出的激励措施，因此特别有必要对其进行研究。分析 ACO 之间的支出差异可能有助于发现节省成本的机会。
对医疗保险索赔进行的横断面分析。
我们根据每个 ACO 的风险调整后支出与其在同一市场（医院转诊区）内平均风险调整后服务费用之间的偏差，将 ACO 分为四分位数。我们比较了每个主要服务类别和 10 个临床病症组中排名前四分之一和排名后四分之一的 ACO 之间的支出，以确定潜在的节省领域。我们假设高调整支出的 ACO 将支出降低至低支出 ACO 的水平，如果这种假设成立，那么模拟支出减少的情况。
在 2016 年，最高支出四分位的 ACO 的地理调整后和风险调整后每位受益人的总支出比最低四分位的 ACO 高出 14%。高支出和低支出 ACO 之间的差异最大，达到 27%，这是在使用熟练护理设施方面——这是 ACO 降低支出比例最大的服务类别。然而，住院护理是导致支出绝对差异的最大因素，占总差异的 37%。如果将高于中位数调整支出的 ACO 的支出降低至中位数，节省将达到 3%至 4%。
通过将变化文献扩展到关注 ACO，我们表明，在市场内部和市场之间都存在有意义的进一步节省机会。
