Dow Division of Health Services Research, Department of Urology, University of Michigan Medical School, Ann Arbor, Michigan.
Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, Michigan.
Clin J Am Soc Nephrol. 2020 Dec 7;15(12):1777-1784. doi: 10.2215/CJN.02150220. Epub 2020 Nov 24.
Despite representing 1% of the population, beneficiaries on long-term dialysis account for over 7% of Medicare's fee-for-service spending. Because of their focus on care coordination, Accountable Care Organizations may be an effective model to reduce spending inefficiencies for this population. We analyzed Medicare data to examine time trends in long-term dialysis beneficiary alignment to Accountable Care Organizations and differences in spending for those who were Accountable Care Organization aligned versus nonaligned.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: In this retrospective cohort study, beneficiaries on long-term dialysis between 2009 and 2016 were identified using a 20% random sample of Medicare beneficiaries. Trends in alignment to an Accountable Care Organization were compared with alignment of the general Medicare population from 2012 to 2016. Using an interrupted time series approach, we examined the association between Accountable Care Organization alignment and the primary outcome of total spending for long-term dialysis beneficiaries from prior to Accountable Care Organization implementation (2009-2011) through implementation of the Comprehensive ESRD Care model in October 2015. We fit linear regression models with generalized estimating equations to adjust for patient characteristics.
During the study period, 135,152 beneficiaries on long-term dialysis were identified. The percentage of long-term dialysis beneficiaries aligned to an Accountable Care Organization increased from 6% to 23% from 2012 to 2016. In the time series analysis, spending on Accountable Care Organization-aligned beneficiaries was $143 (95% confidence interval, $5 to $282) less per beneficiary-quarter than spending for nonaligned beneficiaries. In analyses stratified by whether beneficiaries received care from a primary care physician, savings by Accountable Care Organization-aligned beneficiaries were limited to those with care by a primary care physician ($235; 95% confidence interval, $73 to $397).
There was a substantial increase in the percentage of long-term dialysis beneficiaries aligned to an Accountable Care Organization from 2012 to 2016. Moreover, in adjusted models, Accountable Care Organization alignment was associated with modest cost savings among long-term dialysis beneficiaries with care by a primary care physician.
尽管仅占总人口的 1%，但长期透析的受益人群却占医疗保险按服务收费支出的 7%以上。由于注重医疗协调，责任医疗组织（Accountable Care Organizations，ACO）可能是一种减少该人群支出效率低下的有效模式。我们分析了医疗保险数据，以考察长期透析受益人群与责任医疗组织的协调趋势，并比较了与责任医疗组织协调和未协调的受益人群的支出差异。
设计、设置、参与者和测量方法：在这项回顾性队列研究中，我们使用医疗保险受益人的 20%随机样本确定了 2009 年至 2016 年期间的长期透析受益人群。将与责任医疗组织的协调趋势与 2012 年至 2016 年期间一般医疗保险人群的协调情况进行了比较。使用中断时间序列方法，我们考察了责任医疗组织协调与长期透析受益人群主要结局（2009-2011 年在责任医疗组织实施之前，2015 年 10 月实施全面终末期肾脏疾病护理模式期间）之间的关联。我们使用广义估计方程拟合线性回归模型，以调整患者特征。
在研究期间，确定了 135152 名长期透析受益人群。从 2012 年到 2016 年，与责任医疗组织协调的长期透析受益人群的比例从 6%增加到 23%。在时间序列分析中，与非协调受益人群相比，责任医疗组织协调受益人群每季度每受益人的支出减少了 143 美元（95%置信区间，5 美元至 282 美元）。在按是否由初级保健医生提供护理进行分层的分析中，责任医疗组织协调受益人群的节省仅限于由初级保健医生提供护理的人群（235 美元；95%置信区间，73 美元至 397 美元）。
从 2012 年到 2016 年，与责任医疗组织协调的长期透析受益人群的比例大幅增加。此外，在调整后的模型中，与初级保健医生合作的长期透析受益人群中，责任医疗组织协调与适度的成本节省相关。
